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Book lS^ 

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CflPBUCHT DEPOSm 



An Outline 

of 

Genito - Urinary Surgery 



By 
George Gilbert Smith, M. D., F. A. C. S. 

Genito-urinary Surgeon tc Out-patients, Massachusetts General Hos- 
pital; Assistant Visiting Surgeon," CoUis P. Huntington ^Memorial Hos- 
pitah Captain Medical Corps, U. S. A. ; Fellow American College of 
Surgeons; ]\Iember of the American Association of Genito-urinarj- Sur- 
geons and of the American Urological Association 



Authority to publish 
Granted by the Surgeon-General, U. S. A. 



Illustrations by H. F. Aitken 



Philadelphia and London 

W. B. Saunders Company 

' 1919 



6"^^ 
^'b^ 



Copyright, igig, by W. B. Saunders Company 



MA^' -'^ 1919 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



©CI.A5 15586 



^ 



'V 



V\.<) \ 



TO 

HUGH CABOT 



FOREWORD 



This book has been written ^Yith the idea of presenting to 
students and to general practitioners the important points 
in the symptomatology and pathology of genito-urinary 
diseases. The treatment of these conditions, in so far as it 
deals with medicine or with minor surgery, is given in full; 
when m^jor surgery is indicated, enough of the technic is 
described to give the medical reader an intelligent opinion 
as to the nature of the operation, its aims and its dangers. 

The methods and technic described are by no means the 
only ones possible, but they are measures w^hich I in my 
own experience have found practicable. The case histories 
are almost entirely from my own cases, either in private 
practice or at the Massachusetts General Hospital. 

The articles referred to at the end of each chapter have 
been selected because of their value as original contribu- 
tions, or because they represent the views of men of au- 
thority upon the subject under discussion. 

The drawings were made by Mr. H. F. Aitken from 
actual operations and from pathologic specimens. I take 
this opportunity to express my great appreciation of his 
interested and intelligent cooperation. 

George Gilbert Smith. 

99 Commonwealth Avenue, 
Boston, Mass., 
April, 1919. 



CONTENTS 



CHAPTER I PAGE 

Introduction 17 

Technic 18 

Asepsis in Urethral Instrumentation, 20 — Equipment, 22. 

Endoscopy and Cj'stoscopy 24 

Endoscopy, 24 — Anterior Urethroscopy, 26 — Posterior 
Urethroscopy, 26 — Cystoscopy, 27. 

CHAPTER II 

Urinary Axtiseptics 33 

The Balsamics, 33 — Hexamethylenamin, 34 — Other Drugs, 38. 

CHAPTER HI 

Urinalysis. Tests of Rexal Fuxctiox 39 

Urinalysis 39 

Albumin, 40 — Sugar, 40 — Sediment, 40 — Specimens 
Stained for the Tubercle Bacillus, 41 — Urethral and 
Prostatic Secretion, 42 — Gonococcus Complement- 
fixation Test, 43. 

Renal Function Tests 44 

Technic, 45. 

CHAPTER IV 

CONGEXITAL ]MaeEORMATIOXS 49 

Kidney and Ureter, 49 — Bladder, 50 — Fistula and Cyst of the 
Urachus, 54 — Exstrophy of the Bladder, 54 — Epispadias, 
55 — Hypospadias, 56 — Undescended Testis, 57. 

CHAPTER V 

Diseases of the PE^^s 61 

Chancroid, 61 — Bubo, 62 — Chancre, 62 — Venereal Warts 
(Condylomata), 63 — Balanitis, 64 — Phimosis, 64 — Circum- 
cision, 65 — Paraphimosis, 70 — Cancer of the Penis, 71. 

13 



14 * CONTENTS 

CHAPTER VI 

PAGE 

Diseases of the Urethra 73 

Gonorrhea, 73 — Chronic Urethritis, 87— Non-specific Urethritis, 
90. 

CHAPTER VII 

Diseases of the Urethra {Continued) 95 

Stricture, 95. 

CHAPTER VIII 

Diseases of the Urethra in Women 103 

Acute Urethritis, 103— Chronic Urethritis, 103— Stricture of 
the Urethra, 105 — Caruncle, 105 — Prolapse of the Urethra, 
106 — Urinary Incontinence, 106. 

CHAPTER IX 

Infections of the Prostate and Seminal Vesicles 107 

Acute Infections, 107 — Subacute and Chronic Prostatitis and 
Vesiculitis, 114 — Chronic Non-specific Prostatitis and 
Vesiculitis, 118 — Cure of Gonococcus Infections, 120 — 
Tuberculosis of the Prostate and Vesicles, 123. 

CHAPTER X 

Prostatic Obstruction 124 

Symptoms, 125 — Diagnosis, 128 — Management of Prostatics, 
132 — Cystotomy, 138 — Prostatectomy, 146 — Postopera- 
tive Treatment, 155 — After-treatment of Prostatectomy, 
156 — The Small Fibrous Prostate, 157 — Cancer of the 
Prostate, 158. 

CHAPTER XI 

Diseases of Scrotum and Testicle 163 

Hydrocele; Spermatocele; Hematocele 163 

Diseases of the Spermatic Cord ..." 1 74 

Hydrocele of the Cord, 174 — Varicocele, 175 — Torsion of 
the Spermatic Cord, 176. 

Diseases of the Testicle 178 

Trauma of the Testicle, 178 — Epididymo-orchitis of 
Mumps, 178 — Abscess of Testicle, 181 — Tubercu- 
losis of the Testis, 182— Syphilis of the Testicle, 182— 
Neoplasm of the Testicle, 183 — Epididymitis, 183. 



CONTENTS 15 

CHAPTER Xn 

Diseases of the Bladder 188 

Cystitis, 189— Encrusted Bladder, 195— Chronic Cystitis, 196 
Syphilis of the Bladder, 203 — Bilharzia Infection, 203 — 
Tumor, 204 — Vesical Calculus, 212 — Rupture of the Blad- 
der, 213. 

CHAPTER Xni 

Diseases of Kidneys and Ureters 216 

Urinary Abnormalities, 216 — Pyuria, 219 — Pain, 219 — Dis- 
turbances of Urination, 220 — Fever, 220 — Abdominal 
Tumor, 220 — Renal Insufficiency, 225 — Essential Hema- 
turia, 226 — Decapsulation in Nephritis, 228 — Nephrop- 
tosis, 228— Renal Infections, 232 — Pyelitis of Pregnancy, 
235— Pyelitis of Childhood, 237— Sequelae of PyeUtis, 238 
— Renal Retention, 243 — Renal and Ureteral Stone, 245 
— Renal Tumor, 255 — Rupture of the Kidney, 257. 

CHAPTER XIV 

Genito-urinary Tuberculosis 260 

Kidney and Bladder, 261 — Tuberculous Epididymitis, 265. 

CHAPTER XV 

GoNOCoccus Infection m the Female 272 

Vulvovaginitis of Little Girls, 272 — Vulvovaginitis in Adult, 
276. 

CHAPTER XVI 

Impotence and Sterility 278 

Sterility, 282. 

Int)EX 291 



AN OUTLINE OF GENITO-UKINAEY 
SUEGEEY 



CHAPTER I 



INTRODUCTION 



The management of genito-urinary disease presents to the 
medical profession many problems. Not least of these is 
the problem of bringing about between. the general practi- 
tioner and the specialist that co-operation which is so 
essential to the welfare of the patient. Obviously, the man 
in general practice cannot be expected to make those diag- 
noses which require special instruments and the skill neces- 
sary to their use. No more can he be expected to send 
all his genito-urinary cases to the specialist; indeed, in 
many smaller communities the services of a urologist may 
be quite difficult to obtain. 

Certain conditions, such as hematuria, clearly require these 
services, no matter how inaccessible they may be; other con- 
ditions may be treated with perfectly satisfactory results by 
the general practitioner, provided he will make use of those 
measures of diagnosis and treatment which are within his 
powers. In this he is aided by his knowledge of the patient's 
temperament, general health, and social and economic condi- 
2 17 



l8 AN OUTLINE OF GENITO-URINARY SURGERY 

tions, and in many instances his advice is more seriously ac- 
cepted because of the confidence which past relations with the 
patient have engendered. Yet all of these advantages, val- 
uable though they are, become as nought if he is ignorant of 
the actual pathology underlying his patient's condition. 

Not only must he know the pathology, but he must have a 
very definite idea of the object of treatment and the ends 
which he may hope to attain. In the management of these 
cases, particularly when they are ambulatory and not incapac- 
itated by severe symptoms, there is considerable temptation 
to slip into an aimless, visit-to-visit policy. This must be 
guarded against, first, by the establishment of an exact diag- 
nosis, then by the institution of definite measures to correct 
whatever is wrong. If one feels himself unable to achieve 
either of these aims, he should seek help from someone more 
experienced in this department of surgery, and perhaps under 
the guidance of expert advice carry on the details of treat- 
ment. 

The following pages are an attempt to simplify the rather 
complex subject of genito-urinary disease, to describe in de- 
tail the diagnostic and therapeutic measures accessible to 
every medical man, and to state definitely the boundary at 
which the province of general medicine ends and that of 

urology begins. 

TECHNIC 

In the manipulation which constitutes so large a part of 
genito-urinary therapeusis gentleness is all essential. The 
intact mucous membrane of bladder and urethra is really very 



TECHNIC 19 

resistant to infection. This fact is strikingly proved by 
the excellent condition which the bladder mucosa may show 
in spite of a stream of pus constantly pouring over it from 
a damaged kidney. If the mucous membrane be torn or 
abraded, however, infection by the bacteria which are neces- 
sarily introduced or which are already present will take place 
and set up an inflammatory reaction. Usually mild, this reac- 
tion may be enough to cause peri-urethral abscess, prostatitis, 
and even septicemia. Careful attention to asepsis is neces- 
sary, but even more important is absolute avoidance of 
trauma to the lining of the urinary tract. 

Care in manipulation, therefore, is the first consideration 
in the avoidance of infection. There is another rule which 
must always be observ-ed; that is, instrumentation must be 
followed by lavage. If the posterior urethra has been en- 
tered, the lavage must include the bladder; if only the an- 
terior urethra, an anterior wash will suffice. If the bladder 
is to be included, 8 ounces of the solution are left in that 
viscus and are voided after the catheter is removed. The 
solution used consists of one of the mild antiseptics, such as 
boric acid 2 per cent., potassium permanganate i : 3000 to 
I : 10,000, or silver nitrate i : 5000 or weaker. 

The antiseptic solution, flowing with considerable force 
over the mucous membrane of the urethra, carries out with it 
bacteria which may have been deposited along the canal. 
The strict observance of this rule is imperative. 

The value of urinary antiseptics in the prevention of infec- 
tion from instrumentation I believe to be greatly exaggerated. 



20 AN OUTLINE OF GENITO-URINARY SURGERY 

That they are of the greatest importance in certain condi- 
tions of the genito-urinary tract goes without saying; used 
as a prophylactic measure they certainly do no harm. The 
administration of one of them previous to instrumentation of 
the lower urinary tract is a safe precaution, but is not essen- 
tial, provided instrumentation is properly done. 

Asepsis in Urethral Instrumentation. — In urethral instru- 
mentation there are certain minimum requirements of asepsis 
which must be observed. The hands should be carefully 
washed with soap and hot running water, and dried with a 
clean towel. A sterile catheter lubricant, preferably one of 
the sea-moss preparations put up in collapsible tubes, is 
dropped upon the tip of the instrument. The hands, even 
though washed, are not sterile, and should not touch that 
part of the instrument which will enter the posterior urethra 
— that is, they should not come in contact with the instru- 
ment within 3 or 4 inches of the tip. 

The instrument itself may be sterilized in one of several 
ways; the cleansing process should start at the time the 
instrument was last employed. Immediately after use, be- 
fore the adherent mucus dries, all metal and rubber instru- 
ments should be washed in hot running water, boiled for at 
least two minutes, dried with a clean towel, and put away 
in a closed drawer or case until used. If their container is 
reasonably dust-proof and the instruments are employed 
frequently they may be used without further sterilization. 
If there is doubt of their cleanliness, they should be again 
boiled before being used. Complicated instruments, such as 



TECHNIC 21 

the KoUmann dilator and those with electrically lighted bulbs 
attached, should not be boiled, but can be cleaned by washing 
wdth lukewarm water and soap, followed by alcohol. They 
may then be further sterilized by formalin gas. 

The apparatus generally used for this purpose consists of 
a metal box long enough to hold sounds and catheters, with a 
tightly fitting lid. At one end is a shelf; upon this a pastil 
of formalin is placed. The compartment beneath this shelf 
has a separate opening at the end of the box, and contains a 
small alcohol lamp. The heat of the flame liberates formal- 
dehyd from the pastil, and fills the sterilizer with the gas. 
The in^struments are left in this for twelve hours or more. 

Catheters and bougies made of woven fabric coated with 
varnish should be washed w^ith soap and water, dried and 
sterihzed with formaldehyd gas; some kinds, such as those 
made by certain French firms, may be boiled. They must 
not be allowed to cool while in contact with other instru- 
ments or with the sides of the sterilizer, for the varnish, 
softened by heat, will lose its smoothness if touched. 

Finger-cots for rectal examination should be boiled after 
each case. The infectious organisms to be especially guarded 
against in genito-urinary practice are the gonococcus and 
the Spirochaetae pallida. Both organisms are easily killed 
by heat ; the gonococcus is said to be killed by exposure to a 
temperature of 1 20° F. Immersion of instruments in boiling 
water for two minutes is sufficient therefore to insure against 
their carrying these micro-organisms from one patient to 
another. 



22 AN OUTLINE OF GENITO-URINARY SURGERY 

Equipment. — For the practice of genito-urinary surgery 
there are certain things which are practically essential and 
others which are not essential, but which are very useful. 
In the following list will be given the essential equipment. 
In a supplementary list will be given the equipment which is 
desirable, but not necessary. 

Necessary Equipment 
General: 

Hot and cold running water. 

Sterilizer for boiling instruments. (At least 1 2 inches long.) 

Examining table. (32 or 34 inches high.) 

Microscope, slides, and cover-glasses. 

Irrigating reservoir, glass, capacity at least 24 ounces, 
with rubber tube, glass nozzle, and cut-off. 

Glass graduate or enamel pitcher (capacity 16 ounces). 

Stirring rod, glass pipet. 

Enamel basin. 

Urinometer. Two conical urine glasses. 

Finger-cots. 
Instruments: 

Soft-rubber catheters about Nos. 14, 16, or 18 French. 

Woven bougie catheters, sizes 12, 14, and 16 French. 

Woven coude catheter, size 14 French. 

Stylet of substantial character and a soft-rubber catheter 
to fit it. 

Bougies, filiform and alternate sizes from Nos. 6 to 20 
French. 



TECHNIC 23 

Bougie catheter with fiUform which screws to its tip. 

Metal sounds, sizes 20 to 32. 

Metal or woven bougies a boule, sizes 16, 20, 24, and 28. 
Drugs: 

Catheter lubricant. (The kind made of sea-moss and dis- 
pensed in collapsible tubes is very convenient.) 

Acetic acid, ;^T) per cent. 

Potassium permanganate (3-grain tablets. One in 16 
ounces makes a i : 2500 solution). 

Silver nitrate (tablets, i grain each. One in 8 ounces 
makes a i 14000 solution). 

Boric acid crystals (saturated solution equals 4 per cent.). 

Nitric acid (concentrated) . 

Fehling's solutions A and B. 

Oxalic acid crystals (for removing stains of potassium per- 
manganate) . 

Alcohol, 95 per cent. 

Litmus paper. 
Stains: 

Loffler's methylene-blue. 

AnUine oil gentian violet. 

Gram's solution (IKI). 

Bismarck brown. 

Equipment Desirable, But Not Necessary 

Large syringe for bladder irrigation. (The all metal and 

the glass and metal kinds are the best.) 
Kollmann dilator. 



24 AN OUTLINE OF GENITO-URINARY SURGERY 

Keyes' instillator. 

Centrifuge. 

Formaldehyd sterilizer. 

Various catheters with prostatic curves and tips. 

Straight electrically lighted endoscope. 

ENDOSCOPY AND CYSTOSCOPY 

Endoscopy. — Actual inspection of the urethra, anterior and 
posterior, is a procedure which at times yields information of 
much value. According to some writers it should be per- 
formed in every case of persistent urethral discharge. It is 
their contention that by means of the urethroscope one will 
detect many lesions otherwise overlooked, and that by ap- 
phcations and manipulations through the urethroscope these 
lesions can be cured. 

Views such as these, which may be found in many text- 
books and articles upon the management of urethritis, seem 
to me to place far too much emphasis upon the operation of 
endoscopy. In eight years' experience in clinic and private 
practice I have seen only a few cases in which endoscopy con- 
tributed information of any importance. The ruling out of 
a definite lesion is sometimes helpful, and in this direction lies 
the chief value of endoscopy. 

Papillomata or condylomata of the urethra can be accu- 
rately diagnosed by this measure, and can be treated only by 
fulguration or excision through the endoscope. Small gran- 
ulating areas of the urethra will heal up as quickly when 
treated by dilatation and massage of the urethra upon a 



ENDOSCOPY AND CYSTOSCOPY 25 

sound as when touched with caustic. Lesions of the mucosa 
of the posterior urethra are, as a rule, due to infection of the 
prostate or vesicles. Treatment of the surface alone will not 
suffice — the underlying cause must be removed by prostatic 
or vesicular massage. 

The discovery of congestion of the verumontanum in a 
case of sexual or urinary disturbance does not materially aid 
in relieving the symptoms, and in my experience the appli- 
cation of silver nitrate to the posterior urethra is more suc- 
cessful when made with the Keyes' instillator than when 
applied by a swab through the endoscope. 

In the management of diseases of the female urethra en- 
doscopy is really essential, and should be used much more 
frequently than at present. There are many cases of so- 
called '^cystitis" in which the lesion is not in the bladder, 
but in the urethra. The most effective treatment is by 
means of applications through the urethroscope. 

The technic, both in male and female, is not difficult. The 
simplest instruments are the best. A straight, electrically 
lighted endoscope, consisting of sheath, obturator, and a 
lamp carrier which passes through a small channel separate 
from the main lumen, is the most generally useful. It can be 
used in making applications both to the anterior and to the 
posterior urethra. For inspection of the posterior urethra 
dilation of the canal by water gives a much better picture, and 
can be carried out best by means of a cysto-urethroscope or 
close-vision cystoscopy 

For endoscopy of the anterior urethra no anesthesia is 



26 AN OUTLINE OF GENITO-URINARY SURGERY, 

necessary. For manipulations in the posterior urethra local 
anesthesia secured by the instillation of 2 or 3 ex. of 4 per 
cent, cocain solution is desirable. 

Anterior Urethroscopy. — The penis is drawn out so as to 
eradicate folds in the urethra. The urethroscope is passed 
as far as the triangular ligament (cut-off muscle), the obtura- 
tor is removed, and the instrument is slowly withdrawn by 
the right hand, while the left hand keeps the penis taut. The 
mucosa appears reddish pink, with longitudinal striae of 
deeper red. Granulating areas appear as dull red spots which 
bleed easily. Papillomata and condylomata are easily iden- 
tified. The incision of the orifices of peri-urethral glands is 
mentioned by some writers as a possibility, but is a procedure 
which can be carried out only by operators of unusual deft- 
ness. 

Endoscopy in the female is best done with the patient in the 
knee-chest position. The bladder must be empty. The en- 
doscope is passed into the bladder; the obturator is removed 
and the instrument withdrawn until the diaphragm of the 
sphincter closes over the tip. The walls of the urethra are 
inspected and, if necessary, applications are made with a 
cotton-tipped probe as the endoscope is withdrawn. 

Posterior Urethroscopy. — When the cysto-urethroscope is 
used the instrument is passed into the bladder and then with- 
drawn so that the window is between the sphincters. A 
stream of boric acid solution (2 per cent.) is gently injected by 
an assistant or by means of an irrigator. The fluid distends 
the urethra and enables one to inspect the walls and the veru- 



ENDOSCOPY AND CYSTOSCOPY ' 27 

montanum. Between the internal sphincter and the veru- 
montanum is a depression. The floor of this is frequently 
streaked with red and may show ribs of mucous membrane. 
Then the verumontanum rises abruptly and fills the field 
of vision. Its surface should be smooth and pink; when 
pathological it may be congested, cystic, or papillomatous. 
The anterior aspect of the verumontanum contams the 
opening of the utricle, which, if infected, may exude pus. In 
this connection it is easy to let the imagination run away with 
one's surgical common sense. Such procedures as washing 
out the utricle and catheterizing the ejaculatory ducts sound 
very effective, but unless one is an expert cystoscopist he 
should not attempt them. The case of gonorrhea that can- 
not be cured by the simple measures of dilatation, lavage, and 
massage is a rarity. The chances of doing harm by more com- 
plicated treatment are many. In making applications to the 
verumontanum either the straight endoscope or the posterior 
urethroscope, with window on the side, may be used. After 
the field is wiped dry it is swabbed with silver nitrate solu- 
tion in strength varying from i to 10 per cent. Too strong 
solutions will excite too great reaction. 

Cystoscopy. — The value of cystoscopy admits of no argu- 
ment. Without it diagnosis of genito-urinary disease is in 
many cases impossible. Today the practice of renal surgery 
without preliminary study of each kidney by itself amounts 
to malpractice. 

As to the advisability of the man in general practice at- 
tempting to do cystoscopy there is some difference of opinion. 



28 AN OUTLINE OF GENITO-URINARY SURGERY 

The actual performance of cystoscopy is not difficult. The 
difficulty lies in interpreting what one sees. It stands to 
reason that the opinion of a man who does only ten or twelve 
cystoscopies a year cannot be as reliable as that of the man 
who does several hundred. It would seem better, therefore, 
for each district to support one cystoscopist, whose opinion, 
by reason of his experience, would become of very definite 
value. 

Technic— In our experience the Brown-Buerger cystoscope 
has proved to be the most generally useful. It consists of a 
sheath bearing upon its tip a hooded electric light, an obtura- 
tor which closes the window in the sheath during its intro- 
duction, and observation and catheterizing telescopes. These 
latter contain the system of lenses which enable one to inspect 
a surface which lies parallel to the long axis of the instrument. 
The principle is the same as that of the now famous periscope. 
The catheterizing telescope is smaller in diameter and has 
two grooves for ureteral catheters, and a lever with which the 
tips of the catheters are directed into the ureters. Two types 
of sheath are furnished with each instrument. One has the 
window upon the convex side, the other has it upon the con- 
cave side. The latter is better for '.observation alone; the 
former is used especially in catheterizing ureters in a con- 
tracted bladder. 

Before passing the cystoscope the urethra should be anes- 
thetized by the instillation of 4 per cent, solution of cocain. 
In most cases this will suffice; in very irritable bladders, such 
as the contracted, ulcerated bladder of tuberculosis, a more 



ENDOSCOPY AND CYSTOSCOPY 29 

extensive anesthesia is necessary. For this purpose spinal 
anesthesia is ideal. There is no spasm of the bladder, and 
renal secretion does not diminish as it does when the patient 
is etherized. Before introducing the cystoscope always test 
the light. If that is satisfactory, pass the cystoscope into 
the bladder. Sometimes meatotomy is necessary to allow of 
the passage of the instrument, the caliber of which is 22 or 24 
French. When the tip is in the bladder the obturator is re- 
moved and the bladder is washed with boric acid solution 
through the hollow sheath until the water returns clear. If 
there is persistent bleeding the addition of adrenalin to the 
solution will be of great assistance. The observation or cath- 
eterizmg telescope is then introduced and the bladder filled 
with solution through a tube attached to one of the side 
cocks. The light switch is then turned on and inspection 
begins. 

A routine method of inspection should be followed. First 
the roof is examined, then each lateral wall, and finally the 
base. The condition of the bladder musculature — whether 
trabeculated or not— the presence of diverticula, stones or 
tumors, should be noted. The color and quality of the 
mucous membrane— whether pale and shining, and marked 
by fine capillaries, or whether light-absorbing and of a uni- 
formly reddish color— are important. The character of the 
ureteral jets and of the ureteral orifices should be studied 
next. Lastly, the condition of the bladder neck is examined. 
If the patient is a man, the prostatic outline should be mapped 
out. In cases with obstruction at the bladder orifice the 



30 AN OUTLINE OF GENITO-URINARY SURGERY 

presence of the anterior cleft, denoting enlargement of the 
lateral lobes, or the elevation of the posterior lip by the 
middle lobe or bar, is especially important. 

The search for the ureters is commenced by passing the 
cystoscope as far in as it will go and locating the bubble on 
the roof of the bladder. The instrument is then rotated half 
a circle, so that the window looks directly downward. The 
instrument is then withdrawn until one notices that the lax, 
wrinkled mucosa of the base has changed into a smooth, white, 
elevated area. This is the trigone. By following the upper 
line of the trigone to either side, the eye is carried on to the 
ureteric ridges which run obliquely upward away from the 
observer. Upon the crest of each ridge a short distance 
above its junction with the trigone lies the ureteral orifice. 
In certain instances the orifices are visible only when they 
open to emit urine. 

In bladders distorted by long-standing infection, especially 
that of tuberculosis, the ureters may be impossible to find 
unless the urinary jet is artificially colored. This is best done 
by the intravenous injection of 5 c.c. of 4 per cent, solution 
of indigocarmin in water, which has been sterilized by 
boiling. Within five minutes after the injection the jet 
from a normal . kidney should be colored a deep blue and 
will make easy the location of the ureteral orifice. The 
relative intensity of color of the jets from the two 
ureters will give an idea as to the relative functions of 
the kidneys. 

The passage of the ureteral catheter is a matter of 



ENDOSCOPY AND CYSTOSCOPY 31 

technic which is readily learned by one who has a chance 
for frequent practice. Occasionally the ureteral orifice is 
easily visible, but is hard to catheterize. It is helpful to 
change the amount of fluid in the bladder. Further dis- 
tention will flatten the base and may make catheteriza- 
tion a great deal easier. 

Cystoscopy in Children. — Boys of ten or more and girls of 
six may be cystoscoped if an instrument of 16 or 18 French is 
used. Such a cystoscope is made on the Brown-Buerger 
style, but with only one catheterizing channel. General 
anesthesia is necessary. 

Operative Cystoscopy. — Elaborate operating cystoscopes 
have been invented. Hugh Young's model has a pair of 
jaws which can be used to pick up small stones or foreign 
bodies, or to nip off small tumors. Leo Buerger has devised 
several instruments which may be worked through his oper- 
ating cystoscope. There are scissors, a pair of nippers, and a 
dilator. These are intended chiefly for aiding the passage 
of stones low in the ureter. With the scissors the ureteral 
orifice may be slit, with the dilator it may be stretched. 
The nippers can be used to grasp the stone if it is in sight, or 
to bite out a bit of mucous membrane for diagnosis. Hugh 
Young has devised ingenious appliances which can be oper- 
ated through the cystoscope for applying radium to blad- 
der tumors. 

These intravesical manipulations should be left to the ex- 
pert cystoscopist. They are applicable only in exceptional 
cases, and their usefulness is distinctly limited. 



32 AN OUTLINE OF GENITO-URINARY SURGERY 

Cabot, H.: The Training of the Urologist, New York Med. Jour., May 

25, 1912. 
Schmidt, L. E. : Why Urology Should be Considered a Specialty, Trans. 

Amer. Urological Assoc, 1912, vi, 1-12. 
Thomas, B. A.: The Significance of Specialism with Reference Especially' 

to Genito-urinary Surgery, Jour, of Penn. State Med. Assoc, 1916, 

XX, 101. 



CHAPTER II 
URINARY ANTISEPTICS 

Urinary antiseptics are those drugs which, taken by 
mouth, are followed by the excretion through the kidneys of 
a substance hostile to the growlh of bacteria. Experience 
with various drugs has resulted in the elimination of all but 
two — i. e., the balsamics and hexamethylenamin. Different 
preparations of these two are employed, but the value of each 
depends upon the action peculiar to its parent drug. These 
two drugs act in widely different ways. 

The Balsamics. — These drugs (sandalwood oil, oil of co- 
paiba, and oil of cubebs) are excreted partly by the lungs, 
but chiefly by the kidneys. Cushny (Pharmacology, p. 7^) 
says: ^'The products of the oils excreted in the urine appear 
to have some antiseptic action, for the urine of persons treated 
with them putrefies more slowly than ordinary urine and the 
growth of many of the more common germs is somewhat re- 
tarded by it. On the other hand, there seems some question 
as to how far it is destructive to the gonococcus, which some- 
times grows readily in culture-media made up with such urine 
instead of water. Winternitz therefore attributes the un- 
doubted therapeutic efhcacy of these oils to their lessening 
the inflanmiatory exudate rather than to their antiseptic ac- 
3 33 



34 AN OUTLINE OF GENITO-URINARY SURGERY 

tion, without denying that the latter may also be of some 
importance." 

With these conclusions practical experience closely agrees. 
Of the balsamics, sandalwood oil is best borne by the stomach, 
is less likely to produce skin eruption, and is as efficacious as 
any of the others. 

The chief use of sandalwood oil is to allay inflammation 
of the mucous membrane of the lower urinary tract. In the 
acute stage of gonococcus infections, in acute cystitis of any 
origin, and especially in cystitis due to the tubercle bacillus, 
sandalwood oil best demonstrates its value. Frequency and 
burning on urination diminish. It is given usually in cap- 
sules (lo minims) after or during each meal. In certain 
individuals this drug will cause hyperacidity and gastric 
distress, in others its use is followed by severe colicky pain 
in the kidneys. In these cases the drug had better be 
discontinued. 

With the synthetic products (gonosan, arrhovin, santyl, 
etc.) we have had no experience. Keyes (p. 213, 191 1) 
considers them no more and no less potent than the more 
familiar balsamics. 

Hexamethylenamin of the United States Pharmacopoeia is 
practically the same as urotropin, which is a patented German 
product. It dissolves rather slowly in water, and should be 
taken after meals in order to avoid any irritant effect which 
it might have upon the empty stomach. The drug is inert 
and has no bactericidal effect until it is broken up into 
ammonia and formalin, a process which requires an acid 



URINARY ANTISEPTICS 35 

medium. To the formalin thus set free the drug owes its 
value as a urinary antiseptic. 

In order to get any benefit from its administration the 
urine must be definitely acid. With an acid urine the process 
of splitting off formalin begins in the kidney and is continued 
in the bladder. The value of hexamethylenamin in the treat- 
ment of kidney infections has been doubted, on the ground 
that the drug does not stay there long enough for any impor- 
tant amount of formalin to be set free. In distinctly acid 
urine warmed to body temperature enough formalin may be 
liberated in three minutes to give a definitely positive test 
(Burnam's test) . On theoretical grounds it would seem easily 
possible for urine to remain this length of time in the kidney, 
if we include its passage through the various tubules as well as 
its diffusion through the pelvis. As a matter of practical ex- 
perience there is ample evidence to show that the administra- 
tion of hexamethylenamin influences very markedly certain 
types of renal infection. As the liberation of formalin con- 
tinues in the bladder, one can easily understand its value in 
keeping down infection within that viscus. 

The greatest value of hexamethylenamin is in combating 
colon bacillus infections of the urinary tract. The urine is 
naturally acid in this condition, thereby assisting in the libera- 
tion of formalin, and the colon bacillus is very susceptible to 
a constant bath of formalin. The coccus infections are less 
responsive to this type of therapy. In acute inflammatory 
conditions of the lower urinary tract and in infections by the 
tubercle bacillus hexamethylenamin is contraindicated. The 



36 AN OUTLINE OF GENITO-URINARY SURGERY 

sensitive mucosa is irritated by the formalin in the urine, and 
the local hyperemia and discomfort are increased. 

In order to get the best effect from hexamethylenamin it 
must be administered with an understanding of its behavior. 
The urine must be acid and not too dilute. If not definitely 
acid to litmus paper it may be made more so by the adminis- 
tration of sodium acid phosphate lo to 20 grains three times a 
day. As monosodium phosphate and disodium phosphate 
are both constituents of normal urine, the administration of 
the monosodium phosphate (sodium acid phosphate) does 
not introduce a foreign substance, but simply swings the 
balance on to the acid side. Sodium acid phosphate is 
now supplied in lo-grain tablets, and may be employed 
to the point of causing diarrhea. 

The amount of hexamethylenamin to be given depends upon 
the extent to which it is broken up. Some persons taking 22 
grains a day will liberate enough formalin to give the symp- 
toms of bladder irritation ; 15 grains a day is too small a dose for 
the average adult. As formalin appears in the urine for about 
eight hours after its ingestion, the administration of 15 grains 
three times a day has proved to be a proper dosage for most 
individuals. The drug should be increased to a point where it 
either controls the infection or gives signs of irritation. As 
the liberation of formalin continues after, the urine leaves 
the kidney, it seems fair to say that one should not expect 
renal irritation to occur until after bladder irritation has 
set in; the first signs of an overdose would, therefore, be 
vesical. 



URINARY ANTISEPTICS 37 

The presence of formalin in the urine may be demonstrated 
by Burnam's method. 'This test consists of adding to the 
suspected fluid 3 drops of 0.5 per cent, aqueous solution of 
phenylhydrazin hydrochlorid and then 3 drops of a 5 per cent, 
aqueous solution of sodium nitroprussid, then an excess of 
saturated aqueous solution of sodium hydroxid. It is im- 
portant that the solution to be tested, as well as the sodium 
hydroxid, be slightly warmed, a little more than body tem- 
perature. When formaldehyd is present in solutions of i : 
20,000 or stronger there follows an intense blue color, which 
gradually changes to green, and then after a few minutes to 
brown. In solutions of less than i : 20,000 the first color is 
the mtense green, which passes off into brown. The test is 
delicate down to i : 150,000 or less. When a solution is 
tested and found to be negative, as is the case when urotropin 
is added, it can be acidulated with sulphuric acid, heated to 
boiling, cooled off and tested, when the reaction will be posi- 
tive, due to the breakdown of urotropin into formalin." 

Although this test has proved valuable in establishing cer- 
tain facts in regard to the excretion of formalin, it is no longer 
a necessity. It has been shown^ that hexamethylenamin is 
always excreted promptly by the kidney except in cases of 
advanced interstitial nephritis; that the hexamethylenamin 
in the urine is broken up into formalin in proportion to the 
acidity of the urine. In the administration of hexamethyl- 

^ Smith, G. G.: The Excretion of Eormalin in the Urine; An Inquiry 
into the Accuracy of Burnam's Test, Boston Med. and Surg. Jour., 
1913, clxviii, 713-716. 



38 AN OUTLINE OF GENITO-URINARY SURGERY 

enamin, therefore, one has only to make sure that the urine 
is acid; the production of formahn will then be assured. 

Other Drugs. — Sodium benzoate and salol have been used 
for urinary infections, but in our experience they have ac- 
complished very little. 

HiNMAN, F.: An Experimental Study of the Antiseptic Value of the 

Internal Use of Hexamethylenamin, with the Report of a Simple 

CHnical Method of Quantitative Estimation of Formalin, Trans. 
Amer. Assoc. Genito-urin. Surg., 1913, viii, 235-269. 

4 • ■• 



CHAPTER III 

URINALYSIS. TESTS OF RENAL FUNCTION 

URINALYSIS 

In nine-tenths of all genito-urinary cases the condition of 
the urine gives to the careful observer information of great 
value. In obtaining a specimen for the ordinary examination 
it is enough in the male simply to have the foreskin retracted, 
so that the urine is not contaminated by subpreputial detri- 
tus. In the female, however, a catheter specimen must be 
obtained; unless this is done, one cannot be sure that the 
abnormal cells which may be found are not from the vagina. 
I do not remember having seen bladder infection result from 
this procedure. One should always observe the precaution 
of filling the bladder with an antiseptic after catheterization. 

The general characteristics of the urine, which should be 
examined soon after it is passed, must be noted. These are: 

Odor — ammoniacal or not? 

Color — pale or concentrated; bloody or smoky? 

Opacity — clear and sparkling; hazy; turbid? 

Contents — shreds; clots; bits of tissue? 

Reaction to litmus paper? 

Specific gravity? 

Presence of albumin; sugar? 

Sediment (microscopic examination)? 

39 



40 AN OUTLINE OF GENITO-URINARY SURGERY 

Albumin.— If the urine when passed is hazy, a few drops of 
acetic acid may be added to a small portion. If the opacity 
disappears, it is due to phosphates. The urine thus cleared is 
tested for albumin by nearly filling a test-tube with it, and 
boiling for a few seconds the urine near the top of the tube. 
By holding the tube against a dark background even a very 
slight cloud can be detected. If this cloud does not clear 
upon thcaddition of a few drops of acetic acid it is due to al- 
bumin. If a heavy cloud is present, or if the urine is cloudy 
with some substance other than phosphates, the amount of 
albumin present may be estimated by the nitric acid test (lo. 
c.c. urine filtered, in wine glass; underlay this with concen- 
trated nitric acid, either by decanting or by introducing the 
nitric acid with a pipet). The thickness and density of the 
white ring at the junction of the urine and the acid indicate 
the amount of albumin present. 

Sugar.^ — Boil 5 c.c. Fehling's alkaline solution with 5 c.c. 
Fehling's copper sulphate solution; add a few cubic centi- 
meters of urine and boil. Sugar is indicated by the formation 
of a yellow precipitate. If the test is positive, it must be 
repeated without boiling after the addition of the urine, as 
occasionally other substances besides sugar will cause a pre- 
cipitate when boiled with Fehling's solution. 

Sediment. — The principal objects to be looked for are pus- 
cells, red blood-cells, and casts. Other cells, if present in 
quantities, may have some significance, such as the caudate 
cells of the renal pelvis. In fresh urine the presence of 
more than a few bacteria is noteworthy. 



URINALYSIS 41 

Bacteria are best shown in stained sediment. To obtain the 
sediment for this the urine is decanted out of the centrifuge 
tube (after sedimentation) and the sediment is picked up in a 
pipet or platinum loop, put on a clean slide, dried and stained 
with LoflSer's methylene-blue. Urines containing pus and no 
bacteria in a sediment so tested suggest strongly tuberculosis 
of the genito-urinary tract. As the great majority of infec- 
tions are due to the colon bacillus or to cocci the type of infec- 
tion can often be quickly discovered. 

Confirmation can be obtained by the use of cultures, but 
it is a fact that, not infrequently, stained sediments tell the 
truer tale, as in cultures the change in medium may be ad- 
vantageous to the growth of some kinds of bacteria and 
detrimental to that of others. 

If tuberculosis is suspected, 20 minims of the sediment may 
be injected into the peritoneal cavity of a guinea-pig. After 
five or six weeks the pig is killed and liver and spleen examined 
microscopically for tubercles. Search for the tubercle bacil- 
lus in the urine is likely to be misleading unless the urine is 
obtained by catheter. Otherwise the smegma bacillus, which 
is an acid-fast organism, may appear and simulate the tu- 
bercle bacillus. Unless tubercle bacilli are very numerous 
they will not be found in the ordinary sediment. The fol- 
lowing routine has proved fairly satisfactory in detecting the 
tubercle bacillus in a considerable proportion of cases. 

Specimens Stained for the Tubercle Bacillus. — ^A specimen 
of the suspected urine is centrifuged at high speed for a con- 
siderable time (fifteen minutes to one hour). The sediment 



42 AN OUTLINE OF GENITO-URINARY SURGERY 

is spread thin upon a slide, dried, fixed by being passed 
through the flame, covered with carbolfuchsin (Ziehl's solu- 
tion), and heated to the point of steaming. 

The carbolfuchsin is washed off with Czaplewski's reagent 
or with 20 per cent, nitric acid, followed by 95 per cent, alco- 
hol. This decolorizing process is continued until the smear 
shows only a faint pinkish color. It is then washed in water 
and counterstained with Loffler's methylene-blue. The tu- 
bercle bacilli appear as bright red rods in a blue field (see 
Plate i). 

Urethral and Prostatic Secretion. — Smears from urethra 
(Gram's stain) : A loopful of discharge from within the meatus 
is spread thinly upon a slide, dried, and fixed by being passed 
through the flame twice. The smear is covered with aniline 
oil gentian violet (Stirling's) and heated until it just begins to 
steam; allowed to remain thirty seconds, and then replaced, 
without washing, by Lugol's solution (IKI). This remains 
for thirty seconds. The shde is then washed with 95 per 
cent, alcohol until the violet color has almost disappeared. 
It is then washed in cool water for a few seconds and covered 
with the counterstain (Bismarck brown or eosin) for one 
minute. 

Bacteria, to be called gonococci, must occur within the 
protoplasm of the leukocytes, must be arranged in rectangu- 
lar figures, and must be brown or red, rather small, and bis- 
cuit-shaped diplococci (see Plate i). 

The secretion from the prostate and vesicles in chronic 
cases (which are the ones in which the secretion is usually 



PLATE 1 




Tubercle bacilli in urinary sediment. Stained with carbol-fuchsin, 
decolorized, and counterstained with methylene-blue. Specimen was 
drawn by ureter catheter from a tuberculous kidney which, after removal, 
showed very marked involvement of the pelvic mucous membrane. 




Secretion from the urethra in acute gonorrhea stained by Gram's 
method. Gonococci appear in several of the leukocytes and in the 
large epithelial cell. 



PLATE 2 




Secreti(5n from normal prostate and vesicles. The larger cells are epi- 
thelial, the small oval bodies are the heads of the spermatozoa. 




Secretion expressed by massage from prostate and vesicles infected 
by the gonococcus. The pol}Tnorphonuclear leukocytes indicate in- 
fection. The larger mononuclear cells are from the epithehum. The 
small, oval, homogeneous staining bodies are the heads of spermatozoa. 



tJklNALYSIS 43 

examined) contains gonococci in such small numbers that I 
personally have given up trying to find them. Other organ- 
isms get a foothold, and among them it is difficult to find the 
gonococcus. Even if the search gives negative results, one 
cannot be sure that the infection is cured. The chief value 
of such a smear is to show whether or not there is pus, and in 
what amounts, and whether or not spermatozoa are present. 
For this purpose a methylene-blue stain will do perfectly well. 
The smear should be studied under the oil immersion. The 
normal prostatic secretion shows a homogeneous blue back- 
ground dotted with the heads of spermatozoa, stained a darker 
blue; large mononuclear epithelial cells may occur in large 
number^, and occasionally a few pus-cells. More than an 
occasional polymorphonuclear leukocyte is, to my mind, 
abnormal (see Plate 2). 

Gonococcus Complement-fixation Test. — ^This test is based 
upon the presence in the blood of specific antibodies. These 
are supposed to occur in the blood of individuals who harbor 
the gonococcus; they are the response of the organism to its 
invasion by the gonococcus. If the invasion is slight, as in 
simple urethritis, this reaction may not be aroused. In any 
case the antibodies are not likely to be found until three or 
four weeks after the beginning of the infection. 

The test is carried out according to the same principles as 
the Wassermann test. About 2 c.c. of blood are drawn from 
the median basilic or cephalic vein. The serum is inactivated 
by heat to destroy its content of complement, and a definite 
quantity is mixed with a known quantity of complement 



44 AN OUTLINE OF GENITO-URlNARY SURGERY 

(guinea-pig's serum) and antigen (emulsion of gonococci). 
This mixture is incubated, and if the specific antibodies are 
present they will utilize all the complement in their union with 
the gonococci. Amboceptor (sensitized sheep serum) and 
washed red blood-corpuscles are then added, and the mixture 
is again incubated. If the complement has been utilized by 
the union of antibody with gonococci, the sheep serum (am- 
boceptor) cannot hemolyze the corpuscles, and they remain 
intact (positive test). If, on the contrary, the suspected se- 
rum has no antibodies, complement will be left free to unite 
amboceptor and red blood-cells, and hemolysis of the latter 
will occur (negative test). The reaction is serum + antigen 
±: complement -\- amboceptor -f- sheep corpuscles. Various 
degrees of hemolysis occur; in our experience, a weakly posi- 
tive test may be disregarded as being due perhaps to a so- 
called "group" reaction. 

It stands to reason that as complicated a test as this can 
be of value only when done by an experienced pathologist. 
Even then it should be regarded simply as one of the data 
which aids in the formation of an opinion as to diagnosis or 
question of cure. 

RENAL FUNCTION TESTS 

Estimation of renal function, to be accurate, should be 
based upon the clinical history, the digestive symptoms, the 
blood-pressure, the amount of non-protein nitrogen in the 
blood, and the general condition of the patient. The kid- 
neys themselves are the last organs to be examined. 



RENAL FUNCTION TESTS 45 

In coming to a correct conclusion as regards the renal 
condition of a patient the functional test devised by Rowntree 
and Geraghty is of great assistance. It seems to be the most 
practical of any of the artificial tests, and indicates with sur- 
prising accuracy the changes in the renal function which in 
pathological cases occur from time to time. It must be re- 
membered that the output of phenolsulphonephthalein (upon 
which the test is based) is affected by severe changes in the 
general condition of the patient. Anesthetization, shock, 
severe sepsis, debility — all these influence the amount of dye 
which is excreted. The test registers the functional value of 
the kidneys at the time of the test, and may be quite different 
a week* later. In this sensitiveness resides a good part of its 
value. The drug is thought to be excreted by the epithelium 
of the tubules of the kidney, and acute infectious processes in 
the kidney, which have caused an edema of the renal tissue, 
reduce the excretion to a marked degree. As the infection 
subsides the test registers the corresponding improvement in 
renal function. 

Technic. — A solution of phenolsulphonephthalein contain- 
ing 6 mgm. to the cubic centimeter may be purchased in 
ampules (Hynson and Westcott). Exactly i c.c. is injected 
into the muscles of the back or thigh. A catheter is passed 
and the urine allowed to drip into a test-tube containing about 
I c.c. of 25 per cent. NaOH. When the phthalein begins to 
come through, which normally occurs in seven minutes, a 
pink color appears in the alkahne solution. The catheter is 
then withdrawn ; at the end of one hour the patient urinates 



46 AN OUTLINE OF GENITO-URINARY SURGERY 

or is catheterized. The urine excreted during that hour (since 
the first appearance of the color) is made strongly alkaline 
by the addition of sodium hydroxid, and diluted with tap- 
water up to I liter. A specimen from this solution is then 
compared with solutions containing known quantities of the 
dye, to determine what percentage of the amount injected 
has been excreted. Normal kidney output is 45 per cent, 
(from 40-50 per cent.) in one hour. The estimation may be 
carried out in several ways. Hynson and Westcott have put 
out, for $5.00, a square box about 4 inches in its greatest 
dimension, containing a Httle bottle for the solution to be 
tested, and thirteen bottles containing graded strengths of 
the dye. By direct comparison one arrives at the percent- 
age excreted.^ A similar apparatus for temporary use can be 
made by diluting i c.c. of the phthalein solution to varying 
degrees, and comparing these dilutions with the sample to be 
tested. Test-tubes of the same diameter should be used; the 
solutions fade unless they are strongly alkaline and in sealed 
tubes.2 
In case the urine contains enough blood to obscure the 

1 As these solutions may fade, their strength should be checked up 
occasionally by comparing them with a fresh solution. 

2 As each ampule contains more than 1 c.c, 0.2 c.c. of the excess may 
be added to 200 c.c. of water, thus making a 100 per cent, solution. In 
estimating the amount excreted a specimen of the urine to be tested, al- 
ready diluted to 1000 c.c, is compared with a known quantity of this 100 
per cent, solution. Water is added to the latter until the colors match. 
The total amount : the original amount as 100 : the desired percentage. 
For example: 2 c.c. of 100 per cent, solution is diluted to 8 c.c before the 
proper color is obtained. 8 : 2 as 100 : 25. Therefore 25 per cent, is 
the percentage excreted. 



RENAL FUNCTION TESTS 47 

color of the phthalein, the blood may be coagulated by 
boiling and then filtered off. 

The drug may be given intravenously. In that case normal 
appearance time is three minutes, and about 30 per cent, 
should be excreted in the first fifteen minutes after the color 
appears. 

If one wishes to avoid catheterization the urine may be 
voided one hour and ten minutes after intramuscular injec- 
tion; it should contain about 45 per cent, of the drug. If the 
output is normal, this method is sufficient. If below normal, 
one should know whether the appearance is prompt and the 
amount low, or whether the appearance is delayed. Uni- 
lateral renal disease might account for the first, but for the 
second, bilateral disease must exist. 

More will be said of this test in later chapters. It is an aid 
in many conditions, and to the man in general practice will 
often supply information of considerable value. 

Schwartz, H. J., and McNeil, A.: A Complement-fixation Test in the 
Diagnosis of Gonococcic Infections, Amer. Jour. Med. Sci., May, 
1911. Further Experiences with the Complement-fixation Test in 
the Diagnosis of Gonococcic Infections, Trans. Amer. Assoc. Genito- 
urin. Surg., 1912, vii, 89-108. 

Irons and Nicoll: The Complement-fixation Test in the Diagnosis of 
Gonococcal Infection, Jour. Infect. Dis., 1915, xvi, 303-310. 

Uhle and MacKinxey: The Gonorrhea Complement-fixation Test, 
New York Med. Jour., 1915, cii, 737-739. 

Krotoszyxer, M.: Serodiagnosis of Gonorrhea, Calif. State Jour. Med., 
1916, xiv, 451. 

Smith, L. D.: Complement-fixation Test in Diagnosis and Determina- 
tion of Cure in Gonorrhea, 111. Med. Jour., 1917, xxxi, 222. 

RowNTREE and Geraghty: An Experimental and Clinical Study of the 
Functional Activity of the Kidneys by Means of Phenolsulpho- 



48 AN OUTLINE OF GENITO-URINARY SURGERY 

nephthalein, Jour. Pharm. and Exp. Therap., 1910, i, 579. The 

Phthalein Test, Archiv. Int. Med., 1912, ix, 284-338. 
Sanford, H. L. : A Clinical Study of the Elimination of Phenolsulpho- 

nephthalein by the Kidneys, with a Report of 150 Cases, Cleveland 

Med. Jour., 1912, xi, 763. 
Miller, R. H., and Cabot, H.: The Effect of Anesthesia and Operation 

on the Kidney Function as Shown by the Phenolsulphonephthalein 

Test, Archiv. Int. Med., 1915, xv, 369-391. 
Beer, E.: Kidney Function Tests. Interpretation with Reference to 

Significance of Minimal Excretion of Phthalein and Indigocarmin, 

Ann. Surg., October, 1916, bdv, 434. 
Christian, H. A. : Tests of Renal Function in Cases of Nephritis, Jour. 

Urology, 1916, i, 319. 
Geraghty, J. T.: Kidney Function Tests, Southern Med. Jour., 1917, 

X, 194. 



CHAPTER IV 

CONGENITAL MALFORMATIONS 

Kidney and Ureter. — Many congenital malformations of 
the upper urinary tract give rise to no s^inptoms, and are 
discovered only at autopsy. Others, ordinarily because of 
interference with drainage, offer opportunities for infec- 
tion, stone formation, and hydronephrosis. These are dis- 
covered in the course of investigation with cystoscope, x-ray, 
and pyelogram. Single kidney, horseshoe kidney, dystopic 
(misplaced or pelvic) kidney, double pelvis, double ureter, 
crossed ureter, and single ureter occur alone or in combina- 
tion. Obviously, if they give no symptoms, they require no 
treatment; if they cause trouble, surgery may be necessary, 
but should be undertaken only after a thorough study of the 
urinary tract. 

Horseshoe kidney may cause abdominal pain through pres- 
sure of its isthmus on the structures lying between it and the 
spine. In such an event the kidneys may be separated by 
division of the isthmus. This operation has been done, 
although not often. Either half of a horseshoe kidney may 
develop the same diseases as affect normal kidneys. Stone 
formation, tuberculosis, and pyonephrosis have occurred; 
if one-half of the kidney is sound the affected half may be re- 
moved. The technical difficulties may be considerable, but 
4 49 



50 AN OUTLINE OF GENITO-URINARY SURGERY 

aside from that the diseased half of a horseshoe kidney should 
be treated as though the kidneys were separate. 

Dystopic kidney is very liable to suffer from obstruction of 
its ureter. ' Infection supervenes, causing pyuria, fever, and 
pain. The picture is that of a tender mass low in the iliac 
fossa or in the pelvis. Usually such a kidney cannot be re- 
placed with any prospect of success. Nephrectomy is almost 
always the best procedure. 

Double ureter and double pelvis in themselves are not likely 
to cause trouble. Either half of a double pelvis kidney may 
become infected or tuberculous. Sometimes the diseased 
portion may be removed. 

Bladder. — Diverticula of the bladder may be congenital or 
acquired. The latter are generally small, and are due to 
obstruction at the bladder outlet. Once this obstruction is 
removed, the diverticula cause very little trouble. The con- 
genital type, on the other hand, is usually of good size when 
discovered and tends to constantly increase. It is single in 
the majority of cases (15 out of 19 in Thomas' series), and may 
be situated anywhere in the bladder, although the greater 
number occur at the base. Not infrequently the ureteral 
meatus is drawn into the diverticulum as it grows. Congenital 
diverticula are characterized by the absence of a muscular 
coat, and have a capacity varying from i ounce to 20 ounces 
or more. Cabot has suggested that they are due to the 
maldevelopment of ureteral buds. 

Such a diverticulum prevents the bladder from emptying 
completely. The residual urine becomes infected; symptoms 



CONGENITAL MALFORMATIONS 



SI 



of cystitis appear which are more or less severe according to 
the \'irulence of the infection. The diverticulum may press 
upon the ureter, thereby causing renal retention and infec- 




Fig. 1. — Bladder and diverticulum filled with argentide (Mass. General 
Hospital). 



tion. Advanced cases present a picture similar to that of 
chronic prostatic obstruction — large residuum, urinary infec- 
tion, renal insufficiency. Diverticulum should be suspected 



52 AN OUTLINE OF GENITO-URINARY SURGERY 

when these signs appear in a man under fifty years of age, and 
in older men into whose bladders a soft-rubber catheter passes 
very easily. Only a few cases in women have been reported 
(Lower). The diagnosis must be made between retention 
due to nerve lesions, that due to fibrous obstructing prostate 
(which may occur in men of forty or thereabouts), and that 
due to diverticulum. Radiographs of the bladder filled with 
an opaque fluid (coUargol, argentide, or thorium) often show 
very distinctly the outline of diverticula (Fig. i). Exposures 
must be made at varying angles. Further study should be 
undertaken with the cystoscope before operation is done. 

The treatment consists in excision of the diverticulum, 
provided the patient can stand operation The task is often 
a difficult one, as the inflamed sac becomes firmly adherent 
to the structures among which it Hes and may be in a most 
inaccessible situation. If operation is not done, regular 
catheterization should be instituted, with frequent bladder 
lavage. 

B. M. B. Male, aged twenty-two. Stitcher in shoe factory. M. G. 
H., No. 216903. Entered hospital for the second time August 21, 1917. 
Three years ago was in the Eye and Ear Infirmary with suppurative 
otitis media. Otherwise has always been well until present trouble be- 
gan. One year ago, one week after intercourse, he noticed a purulent 
urethral discharge. This lasted for a week. During this time he had 
great frequency and urgency, and urination was followed by a few drops 
of blood. 

The discharge ceased, but the frequency, urgency, and hematuria 
have persisted, with i>eriods of improvement, for the past year. Fre- 
quency now five or six times during day, same at night. 

He was cystoscoped in the Out-patient Department, but his bladder 
was so irritable that he was sent into the House for cystoscopy under 
spinal anesthesia. The bladder was found to be contracted and very 



CONGENITAL ]\L\LFORi\IATiONS S3 

mucli inflamed. Both ureters appeared normal. Catheter passed to 
left kidney drew normal urine. On right, catheter was obstructed 1 -J 
inches up ureter, opposite a deep retraction in the bladder wall. He was 
thought to have right renal tuberculosis and guinea-pigs were inoculated. 
They were all negative. In August he re-entered the hospital. He was 




Fig. 2. — Radiographic catheter coiled up in diverticulum of bladder 
(Mass. General Hospital). 



found to have a residual urine of 3 ounces. Cystoscopy showed a diver- 
ticulum just outside the right ureter. Catheters passed to both kidne}s 
and drew normal urine. A radiographic catheter was coiled up in the 
diverticulum and .r-rays taken, which proved the diagnosis (Fig. 2;. 
Phthalein test: Total function 20 per cent, first hour, 15 per cent, second 



54 AN OUTLINE OF GENITO-URINARY SURGERY 

hour. Gonococcus complement-fixation test strongly positive. Was- 
sermann negative. 

Operation: Median suprapubic incision, bladder distended. Per- 
itoneum stripped off bladder. Right side of bladder freed from pelvic 
wall, disclosing a thick-walled diverticulum which was adherent to the 
right ureter. The diverticulum was freed as much as possible. The 
bladder was entered accidentally where it was thinned out close to the 
orifice of the diverticulum. A bougie was passed up the right ureter, the 
mucosa of the diverticulum was cut away from its firmly fixed base, and 
the greater part of the sac removed. The bladder was closed except 
near the top, where a tube was inserted. Rubber tissue wicks were 
placed to site of diverticulum. 

The patient made an excellent convalescence and was discharged in 
three weeks. He had no residuum and urinated normally. 

Fistula and Cyst of the Urachus. — The urachus, which in 
the middle third of intra-uterine hfe carries the urine from 
the bladder to the allantois, later closes and persists as a 
fibrous cord extending between bladder and umbilicus just 
anterior to the parietal peritoneum. Occasionally the canal 
remains patent, and allows urine to escape at the umbilicus. 
If the bladder end remains open while the umbilical end 
closes, the condition becomes similar to diverticulum of the 
bladder. Rarely it becomes obliterated at both ends, but 
not in the middle, and a cyst is formed by the secretion of its 
lining epithelium. 

The treatment of any one of these anomalies consists of 
excision of the remains of the urachus. " 

Exstrophy of the bladder is the result of incomplete closure 
of the anterior abdominal wall and of the pelvic girdle as well. 
The bladder everts on to the surface of the abdomen ; the tri- 
gone appears as a rosette of mucous membrane into which the 
ureters open. The sufferer from this malformation is, of 



CONGENITAL MALFORJMATIONS 55 

course, bathed in urine ; the exposed mucosa ulcerates and in- 
fection of the ureters and kidneys results. The condition 
demands operative interference; good results are not easy to 
obtain, but are not beyond expectation. 

There are several ways of meeting the situation. The 
Maydl operation, which has been done a number of times, im- 
plants the trigone and ureters in the anterior wall of the 
rectum. Various operations have been devised to form a 
pouch out of a piece of intestine, and lead the ureters into this 
sac. Charles H. Mayo points out that the formation of a 
pouch gives an infected cavity, and says that, rather than 
trying to get a sterile substitute for the bladder, one should 
endeavor to prevent renal infection by the method of trans- 
plantation of the ureters. He describes an operation which 
has been done in the Mayo Clinic thirteen times, with one 
operative death. It consists of embedding the ureters in 
the wall of the sigmoid for i J inches before bringing the end 
into the lumen of the gut. By implanting the ureter into 
the sigmoid the urinary stream, is diverted and the remains 
of the bladder may be removed entirely. Removal of the 
rudimentary' penis may be necessary to allow good closure of 
the abdominal wall. The operation should be undertaken 
between the ages of seven and fourteen. 

Epispadias. — Incomplete closure of the urethral wall on the 
upper surface of the penis. This is a rather unusual condi- 
tion, requring some sort of plastic operation, depending upon 
the type of epispadias. A transposition of parts has taken 
place; the corpora cavernosa underlie the corpus spongiosum 



56 AN OUTLINE OF GENITO-URINARY SURGERY 

and urethra. The inabiUty to impregnate and the inabihty 
to urinate in a neat and proper way are the reasons for at- 
tempts at cure. Just before puberty is the best time for 
operation. The incontinence sometimes coexistent with the 
physical defect may be reheved by training the bladder. By 
starting and stopping micturition at the word of command, 
the patient comes to acquire control of his vesical sphincter 
(Barney). 

Hypospadias may be "balanitic" — that is, just behind the 
glans^or the opening may be at the penoscrotal angle or in 
the perineum. In extreme cases the scrotum is split and the 
condition suggests hermaphroditism. The balanitic t3^e is 
best let alone. In the more severe types the fibrous bands 
along the under surface of the penis cause the organ to curve 
downward and prevent erection. They should be operated 
upon before puberty. Several operations may be necessary. 
The penis must first be freed from the fibrous bands along its 
under surface. Then, by one of the several methods which 
have been suggested, the urethra is carried out to the head 
of the penis. 

Various substitutes for the urethra have been used to sup- 
ply the missing portion. The appendix and the saphenous 
vein have both been transplanted to the penis, but have not 
always survived. Probably the best operation consists in 
freeing a flap of skin on the under surface of the penis, fold- 
ing it back upon itself so as to make an epithelial lined 
cavity, and covering the raw surface by another flap. 

Complete success is difficult to obtain; the patient must 



CONGENITAL MALFOR^IATIONS ' 57 

be prepared for several operations. Unless the condition is 
relieved, coitus may be impossible and impregnation is al- 
most certain to be so. In order to complete the series of 
operations before puberty it is well to do the first one when 
the child is six or eight years old. 

Undescended Testis. — In many infants the testes do not 
descend completely into the scrotum until some time after 
birth. If descent has not occurred by the end of the sec- 
ond year, the chances of its occurring spontaneously are very 
small. It is probably wise not to interfere until the seventh 
or eighth year unless the accompanying hernia makes earlier 
operation necessary. Attempts to push the gland do^\Ti by 
means of trusses should not be made. If by the seventh or 
eighth year the testis is not in the scrotum, operation should 
be resorted to. 

The reasons for operation are: (i) cosmetic; (2) the un- 
descended testicle is tender and is constantly liable to injury; 
(3) probably because of the constant pressure upon the un- 
descended testis the spermatogenic cells atrophy and ster- 
ility upon that side results. The interstitial cells continue 
to flourish, however, and to supply the internal secretion 
which is necessary for full development and for sexual desire. 
Bilateral cryptorchids are usually sterile, although not im- 
potent. The evidence that undescended testes are especially 
liable to mahgnant degeneration is disputed. Retained, or 
abdominal testicles, should be operated upon as well as those 
in the inguinal canal (Keyes and Mackenzie). 

The operation as described by Bevan laid the foundation 



58 



AN OUTLINE OF GENITO-URINARY SURGERY 



upon which various modifications have arisen. When short- 
ness of the cord does not allow the testis to be placed in the 
scrotum without tension, the structure at fault is not the vas, 




Fig. 3. — Operative treatment of undescended testicle. Stripping the 
cord off the peritoneum so that it may be drawn down more easily. The 
testicle may be carried down behind the deep epigastric vessels, in order to 
do away with the angle in the cord caused by its position in front of the 
epigastrics. 



but the spermatic vessels. Be van recognized this fact and 
lengthened the veins by snipping the adhesions which bound 
the loops together. He also freed the vessels from the peri- 



CONGENITAL MALFORJMATIONS 



59 



toneum behind which they lay, and thereby gained additional 
length. If these means did not suffice, he cut the spermatic 
veins and even the artery, depending upon the artery of the 




/i 



I 



Fig. 4. — Operative treatment of undescended testicle. Lengthening 
the cord by snipping the adhesions which bind together the loops of the 



vas to nourish the testis. Although sloughing rarely follows 
this interference with the blood-supply of the testis, the late 
results of division of the spermatic vessels are shown by Mix- 
ter to be far from good. Atrophy nearly always results. 



6o AN OUTLINE OF GENITO-URINARY SURGERY 

Other writers have suggested that division of the deep 
epigastric vessels, over which the spermatic cord is looped, or 
carrying the testis with its cord behind them, will give a 
straighter course to the spermatic cord and will thereby allow 
the testis to be placed in the scrotum. 

Mayo, C. H.: The Surgery of the Single and Horseshoe Kidney, Ann. 

Surg,, 1913, Ivii, pp. 511-521. Exstrophy of the Bladder and its 

Treatment, Jour. Amer. Med. Assoc, 1917, Ixix, No. 25, 2079. 
Lower, W. E.: Diverticula of the Urinary Bladder, Jour. Amer. Med. 

Assoc, December 5, 1914, Ixiii, 2015-2020. 
Cabot, H.: Some Observations upon Diverticulum of the Bladder, 

Boston Med. and Surg. Jour., 1915, clxxi, 300-302. 
Thomas, G. J.: Diverticula of the Urinary Bladder, Surg., Gynec, and 

Obst., 1916, xxiii, p. 378. 
Gardner, J. A. : Diverticulum of the Bladder, Jour. Urology, 1917, i, 439. 
Barney, J. D.: An Operation for the Relief of Epispadias in the Male, 

Surg., Gynec, and Obst., November, 1916, .594-597. 
Bevan, a. D.: a New Operation for Hypospadias, Jour. Amer. Med. 

Assoc, 1917, Ixviii, 1032. 
Thompson, J. E.: Modern Operations in Hypospadias, Surg., Gynec, 

' and Obst., 1917, xxv, 411. 
Mixter, C. G.: Undescended Testicle in Children, Boston Med. and 

Surg. Jour., 1916, clxxv, 631. 
EiSENDRATH, D.: Undescended Testicle, Ann. Surg., 1916, Ixiv, 324-328. 
Keyes, E. L., Jr., and Mackenzie, D. W.: The Operative Treatment of 

Cryptorchidism, Jour. Amer. Med. Assoc, 1917, Ixviii, No. 5, 349- 

351. 



CIL\PTER V 
DISEASES OF THE PENIS 

Chancroid. — An ulceration caused by the Ducrey bacillus 
and acquired by intercourse. Chancroids are frequently 
multiple. The t^-pical chancroid is an ulceration irregular in 
shape, covered with slough, and without induration. It 
spreads by undermining the skin at its periphery; the under- 
mined skin melts away and leaves a shallow scallop in the 
outline of the ulcer. Inguinal adenitis is a usual accompani- 
ment; the bacillus of Ducrey is the most frequent cause of 
"bubo." 

The incubation period of chancroid is short — about three 
days. The treatment consists in cleanliness and in the 
apphcation of powerful germicides. Crude carbolic acid, fol- 
lowed by nitric acid, is generally sufficient to stop the infec- 
tion. The acids are applied with a cotton-tipped applicator; 
the spaces beneath the skin edges must be thoroughly wiped 
out. If in spite of this treatment the ulcerative process 
continues, the patient should be anesthetized and the ulcer 
cauterized with the actual cautery. This will always cure, 
although two or three applications may be necessary. A 
dusting-powder, such as bismuth subgallate, may be used by 

the patient. 

6i 



62 AN OUTLINE OF GENITO-URINARY SURGERY 

Bubo. — Treatment. — Prompt sterilization of the ulcer will 
often prevent further developments in the inguinal glands. 
With the cutting off of this constant supply of fresh infection 
the glands may be able to overcome the infection already 
present. If they cannot do this, they will proceed to break 
down in a matted, necrotic mass. Poulticing hastens the 
process of resolution, and as soon as fluctuation becomes 
evident the abscess should be incised, the pockets thoroughly 
broken up, and the cavity drained. Keyes advises the use 
of argyrol crystals dusted into the cavity. It would seem 
probable that packing the cavity with some of the newly 
developed antiseptics, allied to Dakin's solution, would 
cause a rapid disappearance of the slough and hasten gran- 
ulation. 

Chancre. — The initial lesion of syphilis. Incubation 
period about two weeks, although it may be much longer 
(six to eight weeks). Chancres are usually single, but may 
be multiple. They are characterized by a rather clean sur- 
face, which tends to be elevated rather than depressed; the 
chancre if small has beneath it a button-like induration; if 
large, the tissues about it present a narrow zone of smooth, 
hard induration. The lesion remains about the same for a 
number of days if untreated, and is not painful. The in- 
guinal glands have a shotty feel; they remain discrete and 
do not mat together as they do when infected by Ducrey's 
bacillus. 

The diagnosis may be made definitely by the finding of 
the Spirochaetae pallida in scrapings from the surface of the 



DISEASES OF THE PENIS 63 

ulcer. This is best done with a microscope equipped with a 
dark stage; some experience in their recognition is necessary. 
There should be in every medical center someone familiar 
mth this work to whom suspicious cases may be sent for 
diagnosis. It is wrong to wait for secondary symptoms or 
for a positive Wassermann reaction, as the chances t)f cure 
are so very much greater if the disease is treated while still 
in the primary stage. Spirochetes have been demonstrated 
in the central nervous system during the early secondary 
stage; it is highly desirable to start treatment before this 
point is reached. Treatment for syphilis should not be 
begun until the diagnosis is fairly positive; at the same time 
every effort should be made to have this diagnosis established 
before the secondary symptoms appear. 

The cases which are most misleading are those due to 
mixed infection, which begin as undoubted chancroids, and 
suggest s>T>hilis only when the secordary symptoms appear. 
Beware of chancroids which develop induration along their 
edges! Unless chancroid responds to treatment within a 
few days it is wise to have a dark stage examination made. 
One injection of salvarsan in the primary stage is worth ten 
injections later. The treatment of syphilis will not be con- 
sidered in this book. 

Venereal Warts (Condylomata). — These are fungus-like 
growths occurring usually in the coronal sulcus and upon 
the inner surface of the prepuce in the male; in women, very 
profuse growths occur, covering the labia and extending to 
the perianal region. They are, so far as is known, not of 



64 AN OUTLINE OF GENITO-URINARY SURGERY 

infectious origin, but are the camp followers of venereal 
disease. In other words, the moist condition of the subpre- 
putial space induced by a chronic discharge seems to be the 
usual predisposing cause. Cleanliness and dryness dis- 
courage their growth. They may be snipped off, and the 
bases c^auterized with silver nitrate, or may be touched with 
glacial acetic acid. The high-frequency current cleans them 
up very quickly. Calomel powder has seemed very satis- 
factory as a drying agent. 

Condylomata of a broad, flat type are sometimes syph- 
ilitic in origin. They occur most frequently about the 
anus. In all such cases a Wassermann test should be 
made. 

Balanitis. — A non-specific infection of the subpreputial 
region, due to retained urine which has decomposed, or sec- 
ondary to a urethral infection. For the former, retraction 
of the foreskin, bathing twice a day with soap and water, 
and the application of boric acid ointment are usually suffi- 
cient. Frequent attacks are an indication for circumcision. 

For balanitis incident to urethritis, subpreputial irrigation 
with a small catheter and hot soaks are of value. As the 
edema subsides, drainage improves and the inflammation 
quiets down. 

Phimosis. — ^A condition of tightness of the prepuce, mak- 
ing retraction difficult. A prepuce may be long — redundant 
— ^but phimosis does not exist unless retraction is interfered 
with. The foreskin should be easily retractable during 
erection. In some babies the foreskin becomes adherent to 



DISEASES OF THE PENIS 65 

the glans ■v\dthout being tight. These adhesions should be 
broken and the prepuce retracted and cleansed ever>^ day. 

Circumcision — Indications. — It is not our belief that every 
male baby should be circumcised. The operation should be 
done, even in boys a few months old, if the prepuce cannot 
be easily retracted. Adhesions between prepuce and glans 
may form unless the foreskin can be retracted and the glans 
penis kept clean. 




Fig. 5. — Tourniquet in place. Ring of novocain infiltration around penis. 

The value of circumcision as a cure for enuresis and for 
various manifestations of nervousness is doubtful, unless 
there is a condition of irretractability which requires circum- 
cision for itself. Phimosis is a definite indication for opera- 
tion, and a redundant prepuce which tends to retain urine 
or which is easily chafed is much better out of the way. 

Technic of Circumcision. — In babies ether should be 
given. We have found the following technic to be satisfac- 
5 



66 



AN OUTLINE OF GENITO-URINARY SURGERY 



tory : The prepuce is split dorsally, the dog's ears trimmed off, 
all bleeding points tied, and the skin and mucous membranes 




Fig. 6. — Upper: Skin incision begun. Lower: Line of skin incision, 
united by two continuous sutures of No. i plain catgut, back- 
sewing for half the circumference. A dressing of boric acid 
ointment is kept on the penis. 



DISEASES OF THE PENIS 



67 



In adults, local anesthesia has given excellent results. A 
tourniquet is put around the penis as near the pubes as pos- 
sible. Novocain (i per cent.) and adrenalin are used. This 
solution is injected under the skin of the penis at the level and 
following the lines of the proposed skin incision. If the 
prepuce can be retracted, a second line of injection is made 




Fig. 7.— Skin incision completed. Incision through mucous membrane 

begun. 



beneath the mucous membrane about | inch from the cor- 
onal sulcus, going entirely around the penis. The skin in- 
cision is then made at a level which allows the new prepuce 
to just cover the corona. The incision is carried around 
the penis, and if the prepuce is not retractable and the 
second line of injection has not been made, novocain is in- 



68 AN OUTLINE OF CxENITO-URINARY SURGERY 




Tjg. 8. — Circumcision of inner layer of prepuce. 




Fig. 9. — Completion of circumcision. 



jected into the mucous membrane of the prepuce from its 
subcutaneous aspect. The mucous membrane is then cir- 



DISEASES OF THE PENIS 



69 



cumcised at about J inch from the corona and the ring 
of prepuce removed. All visible veins, whether bleeding or 

1 




Fig. 10. — Suture of frenum to median raphe. 




Fig. 11. — Half of suture completed. 

not, are ligated with plain catgut. The median raphe on 
the lower surface of the penis is sutured to the frenum with 



70 



AN OUTLINE OF GENITO-URINARY SURGERY 



a suture of No. i chromic catgut. The skin dorsally is su- 
tured to the mucous membrane in the middle hne, and with 
these two points fixed, the union of the skin to mucosa is 
completed either by running or by interrupted sutures. 
Interrupted sutures may have their ends left long in order to 
tie them over a roll of gauze covered with boric acid oint- 




Fig. 12. — Suture completed. After healing takes place the line of suture 
should lie close to corona. 



ment which covers the line of incision. A dressing of gauze 
supported by figure-of-8 strapping of adhesive plaster gives 
support so that the patient may go about his work without 
too great inconvenience. 

Paraphimosis. — A tight prepuce is retracted and becomes 
caught behind the corona. Efforts of the patient to draw it 
over the glans fail; the glans becomes edematous and the 
encircling band so much the tighter. If allowed to go on in 



DISEASES OF THE PENIS 



71 



this way, the tightest part of the prepuce sloughs and the 
constriction is thereby released. 

To reduce a paraphimosis, the operator faces the patient 
and, having lubricated the glans penis with vaselin, clasps 
the shaft of the penis between first and second fingers of 
both hands, and with his thumbs gently forces the edema out 




Fig. 13.— ^Method of reducing a paraphimosis. The thumbs express 
the edema from the glans penis and push the glans through the ring of 
prepuce, while the latter is pulled forward by the interlaced fingers. 



of the head of the penis. Pushing with the thumbs and 
pulling with the fingers he can almost always succeed in 
reducing the paraphimosis. If reduction fails, the con- 
stricting band may be cut, thereby releasing the prepuce. 

Cancer of the penis occurs occasionally in men as young 
as thirty, but usually in men fifty or more years of age. It is 
alleged that cancer of the penis never appears in those who 



72 AN OUTLINE OF GENITO-URINARY SURGERY 

have been circumcised. The growth springs, as a rule, 
from the glans or inner aspect of the prepuce, and appears in 
the preputial orifice as a fungus-like, knobby, often ulcer- 
ated growth. Venereal warts and tertiary syphilis are the 
only lesions likely to be confounded with it. 

The treatment is amputation of the penis, which should 
be accompanied by dissection of both groins. The urethra 
should be cut longer than the stump to allow for its retraction. 
It should be split and sutured over the denuded ends of the 
corpora cavernosa. Good heaUng is aided by instituting 
perineal drainage. A soft-rubber catheter is passed to the 
bladder. The outer end is grasped with a pair of curved 
hemostats, and pushed into the urethra as far as the peri- 
neum. The hemostat is then turned so that the tip may 
be felt through the skin and the overlying tissues incised. 
The end of the catheter is drawn out through this opening 
and fastened in the proper position. The incision closes 
promptly when the catheter is removed. (Barney.) 

RoBBiNS, F. W., and Seabury, F. P.: Treatment of Chancroid, Jour. 

Amer. Med. Assoc, 1917, Ixix, 1217. 
PuSEY, W. A.: Erosive or Gangrenous Balanitis, Jour. Amer. Med. 

Assoc, 1917, Ixix, 1080. 
Cunningham, J. H.: Operative Treatment of Carcinoma of. the Penis, 

Surg., Gynec, and Obst., 1914, xix, 693-699. 



CHAPTER VI 
DISEASES OF THE URETHRA 

Gonorrhea. — Infection of the male urethra by the gono- 
coccus of Neisser is acquired only by intercourse. The 
incubation period may be as httle as twenty-four hours, but 
is much more often two or three days, and it may even be 
longer before the evidences of disease are noticed. The 
history of exposure followed by the appearance of a dis- 
charge is strongly suggestive of gonorrhea, although the 
diagnosis should be made definitely by the finding of the 
organisms in smears (see Chapter II). 

Measures directed toward the prevention of gonorrhea have 
included the use of the condom or the application of some 
germicidal solution to the parts exposed. In the Navy 
methods of applying venereal prophylaxis have consisted of 
anterior urethral irrigations of potassium permanganate 
solution which were given to men who reported exposure 
upon their return from shore leave, or of encouraging the 
men to use the so-called sanitary tube, which contains an 
ointment made of 

Calomel 50 grams 

Vaselin liq 80 c.c. 

Lanolin 70 grams 

73 



74 AN OUTLINE OF GENITO-URINARY SURGERY 

This tube is collapsible and has a urethral nozzle. Im- 
mediately after exposure part of the ointment is injected 
into the urethra and the rest is rubbed on the outside of 
the penis. ^ Both these methods have greatly decreased the 
incidence of venereal disease; the proportion of cases in which 
prophylaxis fails to prevent disease increases with the interval 
which elaspses between exposure and treatment. After six 
hours have elapsed the percentage of failures increases rapidly. 

The regulations of the Surgeon General of the Army re- 
quire a preliminary washing of the genitals with soap and 
warm water, the injection into the urethra of 2 per cent, 
protargol or 20 per cent, argyrol, which must be retained 
for three minutes, and the rubbing of calomel ointment (30 
per cent, in benzoated lard) into the surface of the entire 
penis. The parts are then to be wrapped in soft paper to 
protect the clothing. 

Postmortem examination of criminals who have been inoc- 
ulated before death has shown that thirty-eight hours after 
inoculation the gonococci had only just begun to effect an 
entrance between the epithelial cells. At the end of three 
days the inflammatory process was well under way.^ 

Aborting. — It seems unreasonable to expect success from 
any measure undertaken with a view to ''aborting" an attack 
of urethritis, since the attack would naturally not be dis- 
covered until the organism had penetrated deeply enough 

1 Henry: The Military Surgeon, May, 1912, xxx, 520. 

2 Finger, Gohn, and Schlagenhaufer: Arch. f. Derm. u. Syph., 1894, 
xxviii, 277, abstracted by Keyes, Dis. of the Gen.-urin. Organs, 1911, 
p. 150. 



DISEASES OF THE URETHRA 75 

to set up a diapedesis of leukocytes. Ballenger and Elder, 
however, report good results in very early infections (mthin 
the first twenty-four hours of the discovery of the discharge) 
obtained by sealing up the meatus with collodion after the 
anterior urethra had been injected with 5 per cent, argyrol 
solution. They describe the following technic: 

"The patient should be placed in a reclining posture. 
The penis should be washed and dried, then surrounded 
with a sterile towel. A syringe holding 25 minims is used to 
inject this amount of medicament into the urethra. A 
larger amount does not seem to give any better results and is 
more likely not to be held in the urethra for the necessary 
time. Next, the canal is compressed with the left hand 
while the meatus is dried. Collodion is then applied with 
a camel's hair brush over the meatus and the glans penis for 
J inch around the meatus. The compression of the urethra 
should continue for about five minutes until the collodion 
is thoroughly dry and feels hard to the touch. It is im- 
portant to use plain collodion, U. S. P., 1910, which con- 
tains no castor oil or balsams and which feels hard when 
it dries. No cotton should be placed over the meatus, as it 
will not hold well and is unnecessary. When the collodion 
is thoroughly dried the urethra should be released and a 
condom containing a small amount of absorbent cotton should 
be placed on the penis to protect the patient's clothing in 
case the collodion should break and allow the escape of 
the medicament sealed in the urethra. 

'The patient, who should empty his bladder just before 



76 AN OUTLINE OF GENITO-URINARY SURGERY 

the treatment is applied, should be told not to drink any- 
thing for a few hours and to allow the drug to stay in the 
urethra four or five hours, if he is not compelled to urinate 
before this time has elapsed. When he wishes to void, the 
anterior part of the urethra should be compressed and press- 
ure applied over the collodion, causing it to break at some 
point that affords a line of cleavage, by which the collodion 
may then be pulled off. 

"After allowing the escape of the medicament, the patient 
should drink freely of water for the remainder of the day, 
so as to flush the urethra with bland, unirritating urine. 
The following morning very little water or other liquids 
should be taken, in order to prevent a distended bladder 
from allowing the medicament to stay in the urethra for the 
full time. 

"The treatments may be repeated once a day for five days 
if conditions are favorable. If the discharge continues or 
increases, or if organisms can be found in the secretion on 
the third or fourth day, it may be taken to mean that the 
germs have extended to a point not reached by the medica- 
ment and that this method should be replaced by the usual 
treatment." 

Although I have had no experience with this method, I 
should feel that it might be valuable in cases which begin 
mildly. If a case, when first seen, has a well-developed 
purulent discharge, sealing the meatus would dam back the 
secretion and cause the infection to extend into the posterior 
urethra. 



DISEASES OF THE URETHRA 77 

It has been alleged that heat applied by means of a psychro- 
phore is fatal to gonococci in the urethra. The organism is 
said to be killed by a temperature of 119° F., a temperature 
which might conceivably be induced in the urethral wall 
without causing serious injury. This method has not been 
adopted by the medical profession generally, and even if it 
is able to accomplish the death of gonococci in the tissues, 
the number of cases in which it would be apphcable is small. 
The majority of cases of acute urethritis affect the posterior 
urethra. In these cases the use of heat in the anterior 
urethra alone would be futile, and in the posterior urethra 
would be dangerous. 

Treatment. — Gonorrhea is at first a disease of the wall of 
the urethra. The organisms penetrate the superficial layers 
of the mucous membrane, causing a general edema and 
attracting great numbers of leukocytes. If the infection 
were Umited to the flat surface of the mucosa its duration 
would be brief, for without special centers of resistance the 
gonococcus would soon be vanquished by the processes of 
desquamation and leukocytosis. Unfortunately, the or- 
ganisms enter some of the numerous accessory urethral 
glands — the peri-urethral glands in the anterior urethra, and 
in the posterior urethra the prostatic ducts and the seminal 
passages. Cowper's glands and the utricle of the veru- 
montanum may be infected. Only in from 10 to 20 per 
cent, of cases is the infection confined to the anterior urethra. 
Of the 80 or 90 per cent, of cases in which it reaches the 
posterior urethra a large majority show involvement of the 



78 AN OUTLINE OF GENITO-URINARY SURGERY 

prostate or seminal vesicles. The treatment of these com- 
plications will be taken up in the chapters devoted to the 
lesions of these orsjans. In this chapter only the urethral 
manifestations of gonorrhea will be discussed. 

In the acute stage of urethritis the object of treatment is 
to allay the inflammation. This is done by forcing fluids, 
avoiding all irritating drinks, including "tonics," soda water 
and ginger ale, and spicy or peppery foods. General hygiene 
is very important; the patient should have plenty of sleep, 
as little exercise as possible, free bowel movements, and 
quantities of water. He must avoid exposure to cold. By 
mouth, potassium citrate, lo grains,^ may be given four 
times a day. Capsules containing lo minims of sandalwood 
oil, three times a day, taken during each meal to avoid gas- 
tric disturbance, are valuable in allaying the irritability of 
the mucous membrane of the urethra. In very acute cases, 
with much tenesmus and with blood in the discharge, no local 
treatment at all should be given until the inflammation has 
quieted down. Then one may irrigate the anterior urethra 
through a two-way meatal nozzle with at least i6 ounces of 
very warm, weak potassium permanganate solution (i : 8000) 
every day or every other day. The value of this treatment 
hes largely in the effect of the heat upon the blood-supply 
and upon the metabolism of the mucous membrane. Heat 
increases the desquamation of the epithelial cells in which 

1 1^. Potassium citrate 5 v; 

Water q. s. ad giv.— M. 

Sig. — Teaspoonful in glass of water four times a day. 



DISEASES OF THE URETHRA 79 

the organisms are embedded, and accelerates the migration 
of leukocytes. Potassium permanganate, through its power 
to dissolve the mucus which coats the urethral wall, improves 
the drainage of urethral crypts and washes out masses of 
infectious secretion. Until the very acute stage of urethri- 
tis has quieted down no instrument should be passed into 
the urethra. 

After the first few days in very acute attacks, or earlier 
in the less acute cases, the patient may be instructed in the 
use of the urethral syringe. He should hold the penis with 
the second and tlurd fingers of the left hand, lea\'ing the 
thumb and index-finger free to compress the meatus (Fig. 
14). With the syringe he injects not more than i dram of 
some one of the organic silver salts into the anterior urethra 
and holds it there for from two to five minutes, depending 
on the reaction which follows. Argyrol, used at first in a 5 
per cent, and later in a 10 per cent, solution, and hegonon, 
in I or J per cent, strength, have, in my experience, given 
the best results. The value of these preparations lies in their 
bactericidal power combined with the absence of irritating 
properties. The injection should be made three or four 
times a day. 

Inside of two or three weeks the discharge should be under 
control, the vesical tenesmus, if such exists, should be al- 
layed, and the urine should show less opacity and more 
shreds. The clearing of the urine is due to the disappear- 
ance of the general infection of the mucosa, while the shreds 
are caused bv exudate from residual ulcerations and from 



8o AN OUTLINE OF GENITO-URINARY SURGERY 

infected glands. At this time it is well to ascertain whether 
the process has extended to the posterior urethra (80 to 90 




Fig. 14. — Method of holding penis while making urethral injectrons. 
Thumb and forefinger free to compress lips of meatus as soon as syringe 
is withdrawn. 

per cent, of all cases of urethritis do extend back of the cut- 
off muscle). 

There seems to be a belief among medical men that if the 
patient urinates into two glasses and the second urine is 



DISEASES OF THE URETHRA 8i 

clear, its clarity is evidence that the infection is confined to 
the anterior urethra. This idea is quite wrong, for in the 
less severe infections of the posterior urethra the secretion 
of that portion of the canal is carried out with the first few 
drams of urine and the second urine is clear. It is only 
when the posterior involvement is severe enough for the 
pus to run back into the bladder that the second urine is 
cloudy. 

To determine accurately whether the posterior urethra is 
involved the anterior urethra should be thoroughly irri- 
gated with potassium permanganate solution of considerable 
strength (1:3000); the patient then urinates into two 
glasses. If the first urine is perfectly clear and sparkling, 
there is no posterior urethritis. If the first urine contains 
shreds colored pink, they come from the anterior urethra; if 
the shreds are white or if the urine is cloudy (and does not 
clear upon the addition of acetic acid) the infection has ex- 
tended to the posterior urethra. This test should be ap- 
plied frequently. If posterior urethritis exists it must be 
treated locally as soon as the condition of the urethra will 
permit the passage of a catheter without irritation. The 
rule in the treatment of gonorrhea is to push the treatment 
as fast as possible without traumatizing the urethra or add- 
ing to its irritability. If, therefore, a posterior urethritis 
exists, and the anterior urethra has acquired a tolerance to 
the infection as evidenced by diminution of the discharge, a 
small soft-rubber catheter may be passed with exceeding 
gentleness until it just passes the cut-off, and through this 



82 



AN OUTLINE OF GENITO-URINARY SURGERY 




Fig. 15. — Dressing for penis to be worn during acute stage of urethritis. 
Prepuce retracted. 



catheter, again with gentleness, 8 or 12 ounces of potassium 
permanganate solution of about i : 5000 may be put into the 
bladder. The anterior urethra should be irrigated with 



DISEASES OF THE URETHRA 83 

another 12 ounces as the catheter is being withdrawn. This 
may be carried out every day, and should be done at least 
twice a week. The patient meanwMe continues the use of 
argyrol and sandalwood oil. Some men prefer to fill the 
bladder by gravity. An irrigator is suspended 4 feet 
above the treatment table. The tip of the irrigator tube 
is held tightly against the urethral meatus, and while the 
patient relaxes the cut-off muscle (as if urinating) , hydrauhc 
pressure forces the fluid into the bladder. 




Fig. 16. — Dressing for penis to be worn during acute stage of urethritis. 
Prepuce drawn down over gauze. 

Under this treatment the urethritis should clear up, often 
entirely. At the end of four to six weeks the urine should 
be clear, with perhaps a few shreds. 

The number of injections of argyrol per day may be grad- 
ually reduced and finally stopped altogether. The mucoid 
discharge which often persists will steadily diminish as the 
urethral mucosa regains its normal condition. Hot irriga- 
tions with potassium permanganate or silver nitrate solu- 
tion twice a week will hasten the process. Persistent shreds 



84 AN OUTLINE OF GENITO-URINARY SURGERY 

may be cleared up by gentle massage of the anterior urethra 
upon a sound. 

The patient is allowed to assume his regular ways of liv- 
ing, and if, after a month without treatment, there is no dis- 
charge, the urine is perfectly clear, and there is no infection 
of prostate or vesicles, he may be discharged as cured. 

The recurrence of discharge after cessation of treatment 
means infected glands in the mucosa, or more generally an 
infection of the prostate or seminal vesicles. 

One should not wait for this outbreak before examining 
the prostate and vesicles. In this regard the medical pro- 
fession is either careless or uninstructed, for many a case of 
urethritis is quickly cleared up and discharged as cured by a 
medical attendant who has never examined the patient by 
rectum. These cases later have recurrences in the form of 
gleet, or, believing themselves to be cured, marry and infect 
their wives. 

No case of gonorrhea should he discharged until a careful 
digital examination has been made of prostate and vesicles, 
and a smear of the expressed secretion examined microscopically 
for the presence of pus. 

Not by any manner of means do all cases of urethritis 
run so smooth a course as has been outlined. Of two cases 
treated in just the same way, one will go on to rapid recov- 
ery, while the other will continue to have cloudy urine, per- 
sistent discharge, and perhaps even an epididymitis. With 
the case whose urine does not clear up after several weeks of 
anterior and posterior irrigations, one should palpate the 



DISEASES OF THE URETHRA 8$ 

prostate and vesicles by rectum and determine whether they 
present a uniformly soft, elastic outline, or whether they con- 
tain areas of induration. The secretion expressed by very 
gentle massage should be examined for pus-cells. When the 
second urine is persistently cloudy, the prostate and vesicles 
are practically always found to be infected. This infection, 
in my experience, is in the vesicles in the great majority of 
cases. Infection of the prostate, characterized by a condition 
of stony hardness or by the presence of areas of infiltration, 
does not seem to keep up urethral infection as does involve- 
ment* of the vesicles. When the prostate alone is infected, 
as determined by the examining finger, the urine not in- 
frequently remains perfectly clear, and the prostate slowly 
softens down without treatment and without reinfecting the 
urethra. Invasion of the vesicles is a different matter. The 
process may vary from the slightest possible infection to one 
of such extent that the pus bursts through the wall of the 
vesicle and forms abscesses within the pelvis. Rude or ill- 
advised treatment is followed by dire results — the spread of 
the infection within the vesicle or its extension to the epi- 
didymis. The question arises when to massage the vesicles 
and when to leave them alone. Each case must be judged 
upon its merits. If, after three weeks of irrigations, the 
urine shows no signs of clearing, very gentle massage may 
be tried. It should be done not oftener than twice a week, 
so that the reaction excited by the treatment may subside 
before the next one is due. If the results are good, con- 
tinue; if the benefits are not obvious, drop massage for 



86 AN OUTLINE OF GENITO-URINARY SURGERY 

awhile and confine the treatment to urethral irrigation and 
rectal injections of hot water. Irrigation can do no harm, 
but rough or ill-timed massage can raise all kinds of trouble. 
With the dying down of the vesicular infection the urethri- 
tis clears up. The treatment then becomes chiefly that of 
vesiculitis. (See Chapter VIII.) 

Occasionally one meets a case of acute urethritis in which 
the infection is kept up by a stricture. The discharge is 
dammed back, and will not diminish until the stricture is 
dilated. Dilatation of a stricture in the face of acute infec- 
tion calls for unusual gentleness. The instruments used 
should be small enough to pass without trauma, and should 
not be passed through the cut-off muscle. Copious irriga- 
tion should follow the dilatation. 

Persistence of the discharge from this cause may occur in 
men who have never before had urethritis. A stricture of 
considerable resilience may form within eight weeks of the 
inception of a urethritis. Apparently such strictures form 
as a result of infection of a peri-urethral gland. They may 
be diagnosed by the passage of a bougie a boule through 
the anterior urethra — a procedure which is comparatively 
harmless if gently done. 

N. H. D., age eighteen, contracted his first urethritis in July, 1917. 
His doctor kept him in bed five weeks, as he had fever and great bladder 
distress. In spite of forced fluids and argyrol injections the discharge 
continued. On September 15, 1917, he was sent to me. He had a pro- 
fuse urethral discharge, containing gonococci. The urine was cloudy 
and contained masses of slough. Frequency two or three times an hour. 
A small peri-urethral abscess could be felt at the penoscrotal angle. 
Prostate and vesicles were small and soft. 



DISEASES OF THE URETHRA 87 

He was given potassium permanganate irrigations and argyrol instil- 
lations for two weeks without much improvement. A bougie a boule 
was then passed and a definite stricture, size 21 French, was discovered 
at the penoscrotal angle. This was dilated with sounds. After three or 
four treatments the discharge had practically disappeared, although the 
stricture was still tight to 27 French sound. Dilatation was done when- 
ever the patient came to see me, which was not very often. Meatotomy 
was required to allow the passage of instruments larger than 27 French. 
March 1, 1918, there is no discharge, the urine contains but one or two 
shreds. Sound 29 is tight. Prostate and vesicles are normal. He is 
cured of his gonorrhea, but the stricture has not yet entirely disappeared. 

Chronic Urethritis. — Only a minority of men with acute 
urethritis consult a physician and follow his treatment to a 
cure. Many do nothing for the infection, and if the attack 
is mild, the discharge may cease of itself. Others consult 
friends or druggists; they get some "sure-cure" medicine, 
and when the discharge quiets down, imagine themselves 
well. Still others seek medical advice, are given an injection 
to use, and, to the shame of the profession, are discharged as 
cured without a thorough examination. With one of these 
three stories the sufferer from chronic urethritis presents 
himself for treatment. His condition has existed anywhere 
from three months to years. Examination shows a slight 
colorless or grayish-white discharge which contains epithe- 
Uum, pus-cells, naany odd bacteria, and probably no gono- 
cocci. The urine contains shreds and more or less pus. 
This means urethral inflammation, and the cause of it is 
either a lesion in the urethra, such as a stricture, or pros, 
tatitis or vesiculitis. The former is ruled out by the pass- 
age of a large bougie a boule or of a sound, size 26 or 28 
French. The existence of prostatitis or vesiculitis is d^- 



SS AN OUTLINE OF GENITO-URINARY SURGERY 

termined by rectal examination, together with the examina- 
tion of the secretion expressed by massage. If the urethral 
infection is due to either of these causes, it will be cleaned up 
by treatment directed against the underlying condition. 

In a small proportion of these cases an unusually severe 
ulceration of the urethra will cause areas of induration or of 
granulation which keep up a discharge. This condition will 
be indicated by the persistent presence in the urine of shreds 
of the long, heavy type. 

For such a condition the passage of sounds is the remedy. 
A moderate sized sound — 24 French, for example — should 
be tried first. At subsequent visits larger and larger ones 
must be used until the urethra will take a sound of from 30 
to 32 French caliber without gripping. If the meatus is 
tight i^ must be cut to admit easily at least a 30 French 
sound. 

Meatotomy is done with local anesthesia. A few minims 
of cocain or novocain are injected into the glans between the 
frenum and the meatus. A small knife is passed for | inch 
into the urethra, and the floor of the canal and the skin at the 
f renal side of the meatus divided until a No. 32 sound will 
pass. Incision of the urethral floor for about J inch from 
the meatus, is necessary. Then the mucous membrane of the 
urethra is approximated to the mucous membrane of the 
glans by two stitches of catgut or Pagenstecher, one on either 
side of the center. This stitch, suggested by Barney, checks 
bleeding and tends to prevent adhesion of the cut edges 
(Fig. 17). 



DISEASES OF THE URETHRA 



89 



For persistent urethritis irrigations of silver nitrate solu- 
tion (i : 5000 and stronger) are efficacious. Desquamation 
is increased; new cells come to the surface, and the shreds 
disappear. 

The question of cure in a case of urethritis not complicated 
by infection of the accessory glands is easily settled. The 




Fig. 17. — Placing of the suture after meatotomy to bring mucous 
membrane of urethra down to that of the glans penis, thus covering the 
denuded surface. 



necessary criteria are absence of discharge, clear urine, and 
no evidence of prostatic or vesicular involvement as deter- 
mined by a microscopic examination of the secretion ex- 
pressed by massage. The persistence of a rare shred may be 
disregarded if there is no constriction of the urethra and no 



go AN OUTLINE OF GENITO-URINARY SURGERY 

peri-urethritis to be felt when the urethral wall is palpated 
upon a sound. 

These conditions should be unaffected by a return of the 
patient to his regular habits. There should be no reaction 
following exercise or the use of alcohol. The patient should 
be under observation for a month or six weeks, and if the 
urine remains perfectly clear he may be discharged as cured. 

When the prostate or vesicles have been infected it is 
much more difficult to say just when a cure has been achieved. 
This phase of the question of cure will be discussed in the 
section on Infections of the Prostate and Vesicles (Chapter 
VIII). 

To sum up, the treatment of the acute stage of gonococ- 
cus urethritis is largely expectant. Give the urethra every 
chance to throw off the infection; do nothing to traumatize 
still further the urethral mucosa. Instillations of argyrol 
and irrigations with hot potassium permanganate are always 
safe measures. Continue this policy as long as progress con- 
tinues. When improvement ceases a focus should be sought 
and measures taken to eradicate it. "Slow and sure" is 
better than speedy and sorrowful — and epididymitis. 

Non-specific Urethritis. — ^AU urethritis is not due to the 
gonococcus, even remotely. In certain cases it may be diffi- 
cult to say whether this organism is responsible or not, es- 
pecially if in the past there has been an infection with the 
diplococcus of Neisser. 

An inflammatory condition of the urethra, manifested by 
discharge and by burning on urination, may result from the 



DISEASES OF THE URETHRA 91 

too enthusiastic use of antiseptics. A solution of corrosive 
sublimate of i : 500, for example, is well qualified to stir up 
trouble. Microscopic examination in cases of this type shows 
almost no pus, but quantities of epithelial cells. 

On November 2, 1916, 1 was consulted by a doctoi, thirty-two years of 
age, who had been exposed to infection one week before. As a pro- 
ph\'lactic measure he had given himself a urethral injection of 1 : 500 
corrosive sublimate. Two days later a mucoid discharge appeared in 
which I could find no gonococci. There were many epithelial cells, and 
the picture was that of desquamating mucous membrane. After washing 
out the anterior urethra the urine first voided was clear, showing that 
the posterior urethra was not affected. As the patient had a history of 
gonorrhea when he was fourteen years of age, this test was valuable in 
that it helped to establish the fact that the urethritis was not caused by 
the outbreak of an old prostatitis or vesiculitis. This fact was further 
proved by the absence of pus-cells from the secretion obtained by pros- 
tatic massage. 

As the patient was a very nervous indi\ddual, and would not tolerate 
sounds, the discharge hung on for three months. By that time it had 
gradually disappeared. The urine contained a few shreds, and several 
tiny glands were palpable along the anterior urethra. The complement- 
fixation test was negative on February 12, 1917, so treatment was 
stopped. 

Since then the patient has been perfectly well, with no recurrence of 
the discharge. 

Another kind of non-specific urethritis occurs in men who 
have had a gonococcus infection of the prostate in the past. 
The gonococcus has died out ; a low-grade secondary' nifection 
persists. Under the spur of some exciting cause, such as 
excessive drinking, combined perhaps with unusual sexual 
excitement, these organisms infect the urethra. The ureth- 
ral secretion contains pus-cells, a large number of epithelial 
cells, many bacteria, but no gonococci. The circumstances 



02 AN OUTLINE OF GENlTO-URINARY SURGERY 

under which the discharge appears, as well as the patient's 
guilty conscience, suggest a new infection. Treatment for 
acute urethritis is instituted. The discharge at once sub- 
sides, leaving just enough signs of trouble to tell him that he 
is not cured. These persist; the morning drop and shreds 
do not disappear. At this point or earlier the wise physician 
examines the prostatic secretion after massage and discovers 
why his remedies have failed. Under treatment with sounds, 
prostatic massage, and irrigations of fairly strong solutions 
of silver nitrate (i : 3000) the urethritis clears up. 

J. S. C, aged forty, had a gonococcus infection ten years ago. He has 
been well since. A week before consulting me he had intercourse. Six 
days later he noticed a shght discharge. The urine was clean, with a rare 
shred. No discharge could be seen, though the patient had seen some 
that morning. Examination showed no stricture of the urethra or in- 
volvement of the peri-urethral glands. The vesicles on palpation seemed 
very full, large, and indurated. The secretion from them showed some 
pus-cells. After four treatments — urethral irrigation and vesicular mas- 
sage — all symptoms cleared up and patient refused further treatment. 

A similar condition is found in men who have a prosta-. 
titis or vesiculitis and who never had a gonococcus infec- 
tion. Such cases are not rare. 

B. C, aged thirty. Has been married seven years, and has 3 children. 
Five years ago he was said to have had prostatitis, No known cause for 
it. Three weeks ago was exposed. Two weeks ago he noticed a milky 
discharge from the urethra. Has had no treatment for it. Urination is 
much more frequent than normally. Examination shows a slight dis- 
charge. The smear shows epithelial cells and leukocytes, but no gono- 
cocci. After lavage of the anterior urethra the first urine shows mucous 
clouds, the second is clear. No stricture to 27 French sound. Silver 
nitrate wash and passage of sounds do not arouse the infection as they 
would if the gonococcus were present. The vesicles on palpation seem 



DISEASES OF THE URETHRA 93 

very much distended. Considerable secretion is expressed by massage 
and shows pus. 

After three months of rather irregular treatment the patient developed 
a severe epididymitis. Now, four months after the beginning of treat- 
ment, there is still some discharge and the urine is full of shreds. There 
is distinct improvement in his subjective symptoms. Frequency is now 
almost normal. At first irrigation of the entire urethra was the only 
measure his urethra would tolerate. Now sounds and vesicular massage 
are being employed; the discharge is almost gone, the shreds are smaller 
and fewer in number. 



In some of these cases social considerations call for an 
answer to the question, whether there has been a new infec- 
tion, or whether the urethritis is the result of an old prosta- 
titis. If the discharge is examined within the first week the 
absence of gonococci points strongly to the latter. If the 
patient is not seen until the discharge has largely disappeared, 
one may be aided in the. solution of the problem by the 
complement-fixation test. A fresh infection which has been 
going on for a month or six weeks and has involved the 
prostate or vesicles should give a definitely positive blood 
test. A negative blood test, given a prostatic infection and 
a discharge of more than four weeks' duration, is good evi- 
dence that the infection is of non-specific origin. 

A mild urethral discharge without gonococci, with a con- 
siderable proportion of epithelial cells even in the early stage, 
coupled with a past history of gonorrhea, must always sug- 
gest a non-specific urethritis. This holds true even though 
it follows exposure in a presumably infectious quarter. The 
source of the discharge in such a case will be found to be either 
latent vesiculitis or potential stricture of the urethra. In 



94 AN OUTLINE OF GENITO -URINARY SURGERY 

the great majority of cases of non-specific urethritis silver 
nitrate in sohitions of from i : 3C00 to i : 8000 is the best 
irrigation. 

M. T,' H., aged twenty-seven. Unmarried. Clerk. Gonorrhea four 
years ago, lasting three months. Exposed four weeks ago. For past 
three weeks the lips of the meatus stick together. No discharge seen. 
First urine shows one shred; second is clear. Prostate and vesicles 
normal. Between the meatus and the penoscrotal angle are several ridges 
distinctly perceptible as a bougie a boule, size 24 French, is passed through 
them. Complete clearing up of all symptoms and smoothing out of the 
ridges followed four treatments with sounds and silver nitrate irrigations. 

Ballenger, E. G., and Elder, O. F.: The Technic for Sealing Medica- 
tion in the Urethral Canal, Jour. Amer. Med. Assoc, 1918, Ixx, 834. 

Barney, J. D.: The Management of Gonorrhea, Boston Med. and Surg. 
Jour., 1916, clxxiv, 740-745. 

HOWARD, v.: Military Hygiene, Wm. Wood & Co., 3rd ed., pp. 
122-131. 

LuMB, N. p. L.: Five Hundred Consecutive Cases of Acute Gonorrhea, 
Brit. Med. Jour., October, 1917, ii, 450-452. 

Pollack, C. E., and Harrison, L. W.: Gonococcal Infections, Oxford 
University Press, 1912, 16mo, 222 pages. 

Sanford, H. L.: An Efficiency Test of Dispensary Treatment of 100 
Cases of Gonorrhea, Cleveland Med. Jour., 1913, xii, 813-824. 



CHAPTER VII 

DISEASES OF THE URETHRA {Continued) 

Stricture. — A band of scar tissue in the urethral mucosa 
and submucosa extending around the urethra is a stricture. 
So-called "stricture" of the posterior urethra is always con- 
genital. During development a barrier of mucous membrane 
grows across the canal; the obstruction, therefore, is formed 
of normal rather than of scar tissue. "Contracture" of the 
prostate is virtually a stricture, except that the contraction 
takes place in the prostatic tissue outside the urethra rather 
than in the mucosa itself. 

Stricture of the anterior urethra is commonly due to an 
antecedent gonorrhea and is formed by the contraction which 
follows the cicatrization of inflammatory deposits in the 
urethral submucosa. This process often takes place about 
an infected urethral gland, and is probably continuous with 
the infection which preceded it, beginning as the infection 
subsides, but not giving symptoms until a considerably later 
date. I doubt if stricture ever follows a urethritis which has 
been entirely cleared up. 

Less frequently stricture follows injury to the urethra, such 
as is caused by a blow on the perineum. Partial or com- 
plete rupture of the urethra occurs, with the consequent 
deposition of exudate in its wall. The exudate undergoes 

95 



96 AN OUTLINE OF GENITO-URINARY SURGERY 

cicatrization, and contracts much more rapidly than do the 
strictures of purely infectious origin. Tuberculous strictures, 
though rather rare, must be borne in mind. They are found 
occasionally accompanying tuberculosis of the bladder. 

Strictures may be narrow or broad, hard as cartilage or 
soft and vascular, single or multiple. If multiple, the 
tightest one is always nearest the bladder. Behind a 
stricture the urethra is dilated and infected; the impact 
of the urinary stream keeps up the infection, and the infec- 
tion adds new exudate for cicatrization. So the process 
continues until obstruction to the outflow of urine causes 
hypertrophy of the bladder and dilatation of the ureters and 
kidney pelves. Meanwhile the infection extends back to 
the prostate, the bladder, and the kidneys. The constant 
infection of the prostate, if begun before the age of benign 
enlargement, results in the small, fibrous prostate and appears 
to prevent the formation of adenomata. A study of 50 
men fifty-five years of age or older who had strictures showed 
but one in whom there was any appreciable enlargement of 
the prostate. The infection of the kidneys plus the back 
pressure destroys the renal parenchyma. The avoidance of 
renal destruction furnishes the real reason for early and 
efficient treatment of stricture of the urethra. 

The symptoms of stricture are gleet, frequency of urina- 
tion, and difficulty in expressing the urine. In tight stric- 
tures the stream is small and has no force, but dribbles from 
the penis in a succession of drops. Congestion of the urethra 
brought on by sexual excitement, alcohol, or exposure to cold 



DISEASES OF THE URETHRA 97 

causes the stricture to swell, and an acute retention may 
result. 

The diagnosis of stricture should include a knowledge of 
the situation and size of each contraction ring. These facts 
may be learned by the use of bougies a boule — acorn-tipped 
instruments with slender shafts made of metal or of webbing. 
The largest bougie w^hich the meatus will admit is passed 
until it meets an obstruction. A smaller bougie is then 
passed through the first constriction, down to one through 
which it, in turn, w^ill not pass. In this way the location and 
caliber of each stricture can be ascertained, for as the bougie 
passes through the band its "jump" gives an unmistakable 
sensation to the guiding hand. If the bougie is held up at a 
point just in front of the cut-off, so that one cannot be sure 
w^hether the obstruction is due to stricture or not, the pass- 
age of a fair-sized sound wall give the answer. Stricture grips 
the sound. The sphincter does not. 

Treatment. — The man with a stricture often does not have 
it treated until acute retention overtakes him. If such is the 
case, a prolonged hot sitz-bath may enable the patient to 
void. If it does not, the passage of a filiform bougie will open 
the canal temporarily. In passing a difficult stricture three 
or four filiforms should be passed to the point of obstruction, 
and manipulated in turn. False passages will become filled 
by several of them and one of the others will enter the 
proper passage. Once a bougie is passed in a difficult case, 
it should be fastened in with adhesive plaster strips. The 
urine will find its way out beside the instrument, and the 
7 



98 AN OUTLINE OF GENITO-URINARY SURGERY 

pressure of the bougie will dilate the urethra. A very con- 
venient instrument consists of a filiform to which a woven 
catheter may be screwed. Once the filiform is in, the cath- 
eter may be made to follow, while the filiform coils up in the 
bladder. 

For a few days the urethra will remain patent, or at least 
partially so. After the reaction caused by the passage of the 
bougie has subsided (three to five days) bougies should again 
be passed; this should be done every five to seven days. If 
the stricture is pliable, one should be able to advance at least 
one size (French scale) at each treatment. When the stric- 
ture is dilated to about 20 French, sounds should be substi- 
tuted for bougies. The dilatation must be continued steadily 
until a 29 or 30 French sound passes without being gripped. 
Too rapid dilatation, the sign of which is bleeding, does more 
harm than good. The newly traumatized area becomes in- 
fected and more contraction results. 

The resilient or gristly stricture may resist all attempts 
at dilatation. It will then have to be cut. If situated at or 
in front of the penoscrotal angle, internal urethrotomy will 
suffice and may be done under local anesthesia. 

The anterior urethra is filled with 4 per cent, novocain 
soKition. The Otis urethrotome, an instrument which di- 
lates as a screw in the handle is turned and which has a con- 
cealed knife at the tip, is passed through the stricture and 
dilated until the stricture is stretched tight. The knife 
blade is then withdrawn through the stricture. The urethra 
behind the stricture, being of greater caliber, is not cut. 



DISEASES OF THE URETHRA 



99 



When the knife meets the fibrous band of the stricture it 
divides it. The incision should be made on the roof of the 
urethra, and the process should be repeated until a 31 or 
32 French sound passes easily. An indwelling catheter 
should be left in the urethra for two or three days. The 




Fig. 18. — Sound is introduced with shaft parallel to Poupart's Kga- 
ment. The penis is threaded on to the sound until the point of the sound 
can be felt in the perineum. 



patient should remain in bed for several days, as hemorrhage 
and infection do occasionally occur. 

Strictures in the bulb must be cut through the perineum, 
and the bladder drained for four or five days by a perineal 
tube. These strictures are, of course, divided on the floor 



lOO AN OUTLINE OF GENITO-URINARY SURGERY 

of the urethra. The operation is simple enough if a guide 
can be passed through the urethra previous to operation. 
In impassable strictures, especially when the perineum is in- 
filtrated and perhaps gangrenous, identification of the pos- 
terior portion of the urethra mav be very difficult. Rarely 




Fig. 19.— Handle of sound is swung to middle line and elevated by one 
hand. The first two fingers of the other hand press upon the perineum 
to guide the point of the sound through the cut-off muscle. 

it is necessary to open the bladder above the pubes, and do 
a retrograde catheterization in order to locate the canal. 
When the posterior segment is found it should be dilated 
until the finger can be passed into the bladder. This dilates 
the bladder orifice, which is often narrowed from the cica- 
trization of long-continued infection. Sounds should be 



DISEASES OF THE URETHRA iot 

passed from seven to ten days after operation, and as fre- 
quently thereafter as is necessary to keep the urethra at a 
cahber equal to 29 or 30 (French scale). 

Once a stricture is dilated, whether with or without opera- 
tion makes no difference, it must be held at that caliber by 
the occasional passage of sounds. At first they sTiould be 
passed once a week. As time goes on this may be done less 




Fig. 20. — Handle of sound is carried downward along the line of an arc, 
of which the cut-oflE muscle is the center. After the point has passed the 
cut off, the hand which pre \dously held the sound presses downward upon 
the suspensory ligament, while the other hand guides the sound. The 
handle is depressed until the sound can be felt free in the bladder. 

frequently, but to be insured against the recurrence of his 
stricture a man must have sounds passed once or twice a 
year throughout his life. 

Extravasation of Urine. — Occasionally as a result of ob- 
structed drainage, but more often because of rough instru- 
mentation, so-called ' 'extravasation of urine" occurs. There 
is a brawny swelling of the peri-urethral tissues, beginning 



I02 AN OUTLINE OF GENITO-URINARY SURGERY 

in the bulb and spreading over the scrotum and on to the 
abdominal wall. The penis becomes huge with edema, and 
unless drainage of the most thorough sort is provided patches 
of gangrene develop. It seems clear that the condition is 
not due to the leakage of urine alone, for that has often been 
shown to be comparatively harmless. The malignancy of 
the process is due to infection by a particular kind of anaerobe. 
Immediate section of the stricture and complete drainage of 
the infiltrated tissues must be done. Patients in this con- 
dition are often in wretched shape. In such, spinal anes- 
thesia is the anesthetic of election. 

In the management of stricture one should observe several 
rules: 

1. Do not make a stricture bleed. Bleeding means either 
that a false passage has been made, or that greater reaction 
and contraction will follow the traumatization of the urethra. 

2. For passing or dilating strictures of less than 20 French 
caliber never employ a metal instrument except as follower 
attached to a filiform guide. The point of a small sound is 
very easily poked through the urethral wall. 

3. Always wash the urethra and, if possible, the bladder 
after instrumentation. 

Cabot, H. : Treatment of Stricture of the Bulbar Portion of the Urethra 

by Resection, Partial or Complete, Boston Med. and Surg. Jour., 

1909, cki, 848-850. 
Cabot, H., and Smith, G, G.: The Influence of Stricture of the Urethra 

on the Development of Hypertrophic Changes in the Prostate, The 

Lancet-Clinic, April 27, 1912. 
Keyes, E. L., Jr.: Prognosis of Urethral Stricture, Trans. Amer. Assoc, 

Genito.-urin. Surg., 1915, x, 11-37. 



CHAPTER VIII 

DISEASES OF THE URETHRA IN WOMEN 

Acute urethritis in women is ordinarily only one manifes- 
tation of infection by the gonococcus. As a rule the proc- 
ess clears up quickly, much sooner, in fact, than the involve- 
ment of the cervix which accompanies it. The onset of the 
urethritis is attended by burning urination. The inflam- 
mation may involve the trigone of the bladder, causing 
turbidity of the urine, but the bladder, as a whole, is not 
affected. Under forced fluids and sandalwood oil the proc- 
ess rapidly quiets down, leaving perhaps a subacute ure- 
thritis. The cure of this will be hastened by instillations 
of argyrol, lo per cent, strength, into the urethra, by dilata- 
tion of the urethra ^ith Hank's cervical dilators, and by 
irrigation of the bladder with potassium permanganate. 

Not infrequently the gonococcus gets into Skene's glands, 
situated one on either side of the urethral meatus. Pressure 
upon the anterior vaginal wall expresses the pus with which 
they are filled. To clean out the infection a few drops of 5 
or 10 per cent, silver nitrate solution should be injected into 
their depths by means of a i- or 2-c.c. syringe tipped with a 
needle the point of which has been filed off square. 

Chronic Urethritis. — A not inconsiderable number of women 

who complain of frequent and burning urination are treated 

103 



I04 AN OUTLINE OF GENITO-URINARY SURGERY 

for cystitis, despite the fact that the urine is absolutely nega- 
tive and the bladder, on cystoscopic examination, perfectly 
normal except for undue redness about the trigone and vesical 
orifice. To treat these cases by bladder lavage is to miss the 
point entirely. The urethra is the seat of the trouble. The 
caliber of the urethra should be measured with bougies a 
boule or Hank's dilators in order to rule out stricture. The 
urethra should be palpated upon a dilator, to determine 
whether there is thickening of the peri-urethral glands. 
Examination of the urethra with the straight electrically 
lighted endoscope shows a congested mucous membrane, 
streaked with deeper red. Some of the patches of red may 
be almost granular and bleed easily. This examination is 
best made with the patient in the knee-chest position. The 
bladder should be thoroughly emptied of urine, by the 
catheter if necessary, as urine running into the endoscope 
spoils the view. 

For this condition the application of lo per cent, silver 
nitrate to the entire urethral lining by means of cotton- 
tipped applicators gives excellent results. The treatment 
should be given not oftener than once a week, and it is a good 
plan to substitute for every third treatment of this kind a 
simple dilatation and irrigation. 

These cases of chronic urethritis seldom follow a gonococcus 
infection. I have seen one whicli was very evidently the 
last vestige of a pyelitis. They occur most frequently in 
unmarried women, and often at about the time of the meno- 
pause. Unquestionably improvement in the general condi- 



DISEASES OF THE URETHRA IN WOMEN 105 

tion of the patient -will improve the urethritis. H. D. Furniss 
has described such a case which was helped very Httle by 
local treatment, but which seemed to recover entirely follow- 
ing tonsillectomy. 

The great relief which can sometimes be given to such cases is illus- 
trated by the history of Miss I. deL., age twenty-six, who had been at 
Rutland Sanatorium for pulmonary tuberculosis. She came to the Out- 
patient Department of the Massachusetts General Hospital complaining 
of great frequency, burning, and such urgency that unless she could find 
a toilet immediately she would lose control of the urine. We expected to 
find her a case of urinary tuberculosis, but were surprised to find the urine 
absolutely normal. Cystoscopy showed a normal bladder. The urethra, 
however, was as red as a piece of raw beef. After about ten applications 
of silver nitrate she considered herself so well that, some two years ago, 
she stopped treatment altogether. I have seen her at intervals since; 
the improvement has been permanent, and except during her periods she 
has no urinary symptoms at all. 

Stricture of the Urethra. — Although not frequent, stric- 
ture in women is by no means rare. As in man, it follows 
an antecedent infection. The symptoms are those of ure- 
thral irritation, i. e., frequency and burning. The diagnosis 
is made by the passage of bougies a boule, sounds, or dilators. 
The treatment consists m gradual dilatation, which gives 
very satisfactory results. 

A caruncle is a bright red, elevated papilla situated at the 
urethral orifice, nearly always on the vaginal side. Fre- 
quently it is exquisitely sensitive; half of the cases studied by 
Young had frequent, painful urination. Four t>T>es have 
been described — the angiomatous, the granulomatous, the 
papillomatous, and the epitheliomatous. The last group, on 
microscopic examination, presents the picture of epithelial 



lo6 AN OUTLINE OF GENITO-URINARY SURGERY 

cancer. As cancer of the female urethra is rare, while 
caruncle is very common, it would seem that this resem- 
blance is apparent rather than real. 

Caruncle is best treated by removal, either by cauteriza- 
tion, fulguration, or excision. Local anesthesia — a few drops 
of novocain injected beneath the little tumor — suffices. 
About a third of the cases removed, whether by cautery or 
by the knife, recur. 

Prolapse of the urethra is most likely to occur in elderly 
women. A ring of redundant urethral mucosa surrounds 
the orifice. The exposed surface may ulcerate or may be- 
come very edematous. The best treatment consists of ex- 
cision of the collar of prolapsed membrane, with suture of 
the cut edges. 

Urinary incontinence, if not due to a nerve lesion, pelvic 
prolapse, severe cystitis, or overflow bladder, is due to a 
laxity of the urethral sphincter. This condition may be 
remedied by an operation which brings together beneath the 
bladder neck enough fibers of the detrusor muscle of the blad- 
der wall to form a sort of buttress beneath the trigone and the 
internal urethral orifice. 

BuGBEE, H. G.: Frequency cf Urination in Women, Jour. Amer. Med. 
Assoc, Ixviii, 693-699. 

Shallenberger: Chronic Urethritis in Women; Diagnosis and Treat- 
ment in Obscure Urethral Pain, Jour. Amer. Med. Assoc, 1916, 
Ixvi, 101 L 

Young, E. L., Jr.: Urethral Caruncle, Boston Med. and Surg. Jour., 
dxxii, 822-824. 



CHAPTER IX 

INFECTIONS OF THE PROSTATE AND SEMINAL 
VESICLES 

Acute infections of prostate and vesicles are practically 
always the result of invasion of these structures by the gono- 
coccus. Prostatic abscess due to the colon bacillus does 
occur, but is infrequent compared with the infections for 
which the gonococcus is responsible. 

The prostate may be likened to a sponge into the interior 
of which gonococci have penetrated and have set up little 
foci of suppuration. Each little abscess is surrounded by a 
zone of inflammation. These indurated areas give upon pal- 
pation a hard, nobby sensation. The prostate is somewhat 
enlarged, and its chief characteristic is an absence of the soft 
elasticity of the uninfected gland. 

Infection of prostate and vesicles takes place in more than 
half the cases of acute gonorrhea. In most of these the proc- 
ess never becomes acute enough to give symptoms; it is 
evidenced only by the persistence of urethral infection, by 
the abnormal findings on rectal examination, and by the 
presence of pus-cells in the prostatic secretion expressed by 
massage. 

In a few cases the infection runs a more virulent course. 

The gland becomes swollen, hot, and very tender. There is 

107 



Io8 AN OUTLINE OF GENITO URINARY SURGERY 

frequency and urgency of urination, and a general febrile 
reaction. With rest in bed and hot rectal irrigations the 
process either quiets down or goes on to abscess formation. 
Usually it follows the former course; less frequently, the 





Fig. 21. — Dissection of the base of the bladder, showing prostate, seminal 
vesicles, vasa deferentia, and one ureter. 



latter. Even if a definite abscess does form, operation is 
rarely necessary, as the majority of prostatic abscesses rup- 
ture spontaneously through the urethra or through the 
rectum. If rupture does not speedily occur, with marked 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 109 

relief of symptoms, the abscess should be dramed. A pre- 
anal incision, through which the posterior aspect of the pros- 
tate may be reached without disturbing the cut-off muscle, is 
the best method of approach. 

Acute infections of the seminal vesicles, like those of the 
prostate, are almost always due to the gonococcus. Edema 




Fig. 22. — Seminal vesicle and ampulla of the vas deferens with the 
posterior half cut away, sho^ving the tremendorsly complicated arrange- 
ment of the interior. The absence of drainage facilities explains why in- 
fection persists so long in the vesicles. 

of the mucosa shuts the ejaculatory ducts ; the infected secre- 
tion backs up into the vesicles and there sets up a marked 
reaction. Studies of the seminal vesicles by Pickel have 
shown that in the majority of cases they consist of complex, 
convoluted tubes, the mucous membrane of which is full of 
glands and crypts (B. A. Thomas). Great opportunities are 
offered infecting organisms to form foci in these crypts. In 



no AN OUTLINE OF GENITO-URINARY SURGERY 

the majority of cases the eradication of infection is made diffi- 
cult by the presence of diverticula given off from the main 
tubule. Pockets are formed, the drainage of which through 
natural channels is very insufficient. Into this maze of 
crypts, pockets, and blind by-ways the gonococcus pene- 
trates and forms small foci of suppuration. Inflammatory 
reaction about these foci causes thickening of the wall of 
the vesicle. Thus a stiff -walled, infected cavity is formed, a 
condition which in no way helps in clearing up the infection. 
Acute infection of the vesicles may cause pain in the groin 
and backache because of distention of the sacs by pus and 
retained secretion. Occasionally the vesicles rupture, with 
the escape of pus into the perivesicular tissue. The abscess, 
kept from the rectum by the sheet of fascia (Denonvillier's 
fascia) which separates prostate and vesicles from the rectum, 
may point in the perineum. 

P. N. H. Married, aged twenty-nine. Gonorrhea eleven years ago, 
apparently cured. Married two years later, wife never pregnant. 
After marriage his discharge reappeared. His wife had an "abscess 
about the womb." Four weeks ago he had extramarital intercourse, 
followed in one week by a urethral discharge. For two days he has had 
difficulty in voiding, and the rectum has been very sore. Examination 
showed a profuse urethral discharge which contained gonococci. No 
stricture found. Testes and epididymes normal. By rectum, left side 
of prostate showed much induration and tenderness. The urine was 
hazy with pus and showed a slightest possible trace of albumin. 

He was put to bed and given daily rectal injections of hot water. The 
condition of the prostate and vesicles became worse, and after ten days he 
was sent to the hospital. There he was kept under observation for a 
week or more, now better and again worse. He ran an evening tempera- 
ture of 2 or 3 degrees elevation, and an area of induration began to de- 
velop in the perineum. He had a great deal of pain. The urine had be- 
come clear. Operation was decided upon. Under spinal anesthesia a 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES III 

curved preanal incision was made. The rectum was dissected back 
and an abscess containing several drams of pus was opened. The 
abscess ca\dty extended upward to the left seminal vesicle. The dis- 
section was carried upward until the vesicles were exposed. The left 
vesicle was identified and freely incised, with the escape of thick pus. 
The right vesicle was not identified. A rubber tissue wick was placed 
over the vesicle and the wound closed. 

Operation was followed by immediate relief of pain and fall of tem- 
perature. The wick was removed at the end of a week and the wound 
healed quickly. He returned to work in New Hampshire and was seen 
occasionally. Two and a half months later examination showed clear 
urine, no urethral discharge. Prostate and vesicles felt matted together. 
The secretion expressed by massage showed spermatozoa and no pus at 
all. Complement-fixation test was negative. Having divorced his wife, 
he was about to be married again. 

Invasion of the blood by the gonococcus may take place, 
accompanied by fever and perhaps causing metastatic growths 
in endocardium or joints. Septicemia, as evidenced by en- 
docarditis and more frequently by arthritis, is not a common 
complication. The former manifestation may often escape 
observation, but, so far as is known, it is not at all frequent. 
Arthritis of greater or less severity occurs chiefly among the 
cases treated improperly or not at all, and in my experience 
is nearly always due to an infection of the vesicles. 

Arthritis of gonococcus origin is usually polyarticular. 
Fleeting pains may be felt in a number of joints, but the 
process finally settles in only a few of these. The small 
joints of the feet are especially prone to become involved, 
and the knee is perhaps the next most frequent. The process 
affects the synovial surfaces, and has the same tendency to 
form fibrous tissue that it has in the urethra. 

Gonococcus arthritis may be divided into two forms — the 



112 AN OUTLINE OF GENITO-URINARY SURGERY 

very acute, fulminating type, in which the joint becomes 
swollen, red, exquisitely tender, and later suppurates, and the 
more chronic type, in which the process comes on less ab- 
ruptly, and consists of peri-articular swelling without any of 
the signs of acute inflammation. In the first type, immediate 
opening of the joint, washing it out with salt solution or 
sterile water, and closing it tight with immobilization, is the 
only way to save the motion of the joint. For the less acute 
type, complete rest at first, followed later by passive, then 
active, motion. 

In addition to treatment of the joints, treatment directed 
against the focus from which the infection is derived is a 
necessity. This usually consists in regular massage of the 
prostate and vehicles. Not only does this clean up the focus, 
but it seems to give immediate results through the vaccination 
of the patient with his own organisms. Massage, in other 
words, liberates gonococci or their toxins, which increase the 
bodily resistance to the infection. To intensify this action 
a course of six injections of gonococcus vaccines may be 
given. The dose should be as follows: 
500,000,000 the first day. 
750,000,000 the third day. 
1,000,000,000 the sixth day. 
1,250,000,000 the ninth day. 
1,500,000,000 the twelfth and fifteenth days. 

If the arthritis does not improve under these measures, the 
question of draining the seminal vesicles by the operation of 
vesiculotomy should be considered. 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 113 

Seminal vesiculotomy has been advocated for this condi- 
tion. A few genito-urinary surgeons are enthusiastic advo- 
cates of the operation. Unquestionably, there are cases in 
which prompt drainage of the vesicles gives much speedier 
and more complete results than any other method of treat- 
ment. The operation is not without risk. It may be at- 
tended by considerable shock. One case operated by me 
died a week later, apparently from gonococcus septicemia. 
In my opinion the operation should be reserved for (i) 
cases of very acute vesiculitis in which the ordinary methods 
fail to give relief; (2) cases of gonococcus arthritis which 
show no definite improvement after massage of the vesicles 
has been faithfully carried out for two or three months. 

Medication of the vesicles by the injection through the 
lumen of the vas deferens of some germicide, such as argyrol, 
is not without advocates. Under local anesthesia a small in- 
cision is made in the scrotum. The spermatic cord is pressed 
into the incision and the vas is isolated and opened. The 
needle of a lo-c.c. syringe is passed into the canal toward the 
body and the solution to be used is injected. Except by a 
few genito-urinary surgeons the method has not been gener- 
ally accepted. 

Vaccines are employed quite extensively in the above con- 
ditions, as well as in other forms of gonococcus infection. 
It is hard to judge accurately their true value. My own ex- 
perience with them has not convinced me that they are 
really helpful except in arthritic cases. If employed at all, 
they should be used simply to increase the patient's resist- 

8 



114 AN OUTLINE OF GENITO-URINARY SURGERY 

ance to the invading organism, and not as a substitute for 
local treatment. 

So much for acute infections of prostate and vesicles; they 
occur with relative infrequency, considering the vast number 
of infections of these organs which occur every year. In 
managing such cases one should pursue an expectant policy 
until it is clear that there is an abscess which shows no signs 
of spontaneous drainage. 

Subacute and Chronic Prostatitis and Vesiculitis. — In 
the great majority of men infected by the gonococcus the 
infection involves the prostate or vesicles, or both. Herbst 
says: "In over 75 per cent, of cases in which the gonococcus 
invades the male urethra it travels back of the cut-off muscle 
and into the posterior urethra, and in most, if not all, of them 
the ejaculatory ducts and subsequently the seminal vesicles 
become involved." 

It is my own belief, the correctness of which is not easy to 
prove, that infections of the prostate quickly clear up of their 
own accord. Infections which persist, though often called 
prostatic, are really of the vesicles. In comparatively few 
cases is this posterior infection severe enough to cause symp- 
toms troublesome to the patient. . In most, a cloudy second 
urine, with perhaps some frequency for a day or two, are the 
only outward signs of the spread of the infection. In many 
of these cases the urethritis clears up completely. In others 
it gradually diminishes and persists as a slight dampness at 
the meatus, accompanied by an uneasy feeling on the part 
of the patient that there is still something wrong. 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 115 

If patients of either type come into the physician's hands, 
examination of the prostate and vesicles should be made. No 
case of gonococcus urethritis, no matter how trivial, should 
be discharged without an examination of the prostatic and 
vesicular secretion. If the patient has been getting posterior 
irrigations, the bladder should be filled with antiseptic solu- 
tion. If his entire trouble has apparently been anterior, the 
examination may be made with the bladder full of urine. 
The examining finger, encased in a w^ell-lubricated finger-cot, 
is inserted through the anus. This is made easier if a little 
lubricant is smeared about the outside and the buttocks are 
separated by the fingers of the left hand. The patient bends 
for\vard over a table or chair and the right forefinger is in- 
serted slowly. Directly beneath the finger, separated from 
the anal sphincter by about | inch of soft tissue, lies the 
prostate. Only by experience do we learn to distinguish the 
normal from the abnormal gland. There are two types of 
normal prostate — the small, soft kind, and the large, elastic 
kind. If the lobes are hard to the touch or feel shotty, the 
gland is almost certainly infected. Such a prostate may 
remain in the same condition for years, with no sign of 
trouble in the urine. The induration is due to areas of scar 
tissue, the result of focal infection. 

The finger should easily reach the upper border of the pros- 
tate. Above, extending upward and outward close to the 
pelvic wall, lie the seminal vesicles. These may be normal 
even if they are palpable; if such is the case, they are soft and 
one can feel the movement of the fluid within them as the 



Il6 AN OUTLINE OF GENITO-URINARY SURGERY 

finger presses down. If they are infected, as they are in a 
large majority of cases, they feel thickened, or contain in- 
durated masses, or are plastered on to the pelvic wall in such 
a way that they form a shelf from side to side. 

By very gently but persistently stroking the vesicles from 
above downward, and by rubbing more firmly upon the pros- 
tate, a few drops of secretion may be expressed from the 
mouth of the penis. This is examined for pus, as described 
in Chapter II. 




Fig. 23. — Diagram of prostate and vesicles. Arrows indicate direction of 

massage. 

Examination of this secretion for gonococci is really a use- 
less task. Even if present, they are few in number and 
probably more or less atypical in form, so that their recog- 
nition is not certain. If search is negative, one cannot be 
sure that the infection has disappeared. The specimen of 
secretion on the slide represents so small a portion of the 
whole that its testimony on this point is not valuable. 

The presence of pus-cells in any considerable number 
means that the posterior structures are, or have been, in- 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 117 

fected. In the secretion from normal prostates rare pus-cells 
may occur, but the presence of more than one cell in every 
four or five high-power fields indicates an inflammatory 
process. 

The inflammatory process so indicated may be due to the 
recent infection, or may have foUowed a previous infection by 
the gonococcus or by other organisms. One must consider 
the history of the case in this connection. The history of a 
previous gonorrhea, since the inception of which there has 
always been a little discharge, strongly suggests that the 
prostatic condition is a relic thereof. A perfectly negative 
past history, with a. present attack of urethritis, makes it 
equaUy probable that the pus in the prostate is due to the 
current gonorrhea. 

In either case the existence of prostatic or vesicular in- 
fection coexistent with or following a gonococcus urethritis 
constitutes a definite indication for the treatment of pros- 
tate and vesicles. 

L. A. C, aged twenty-nine, came to me on March 30, 1915. He wished 
to marry, but feared to do so because of a persistent gleet. Gonorrhea 
twice, last time in 1910. This attack lasted about three months. He 
had never had massage of prostate. Since 1910 he has had a slight 
discharge. The urine is clear. Except for a varicocele, external genitals 
are normal. The prostate on rectal palpation is large and soft, the vesicles 
thick and indurated. Much secretion expressed, showing some pus and 
spermatozoa. Complement-fixation test "moderately positive." He 
was treated once a week for two years; massage was the chief treatment, 
although full-sized sounds were frequently passed. In November, 1916, 
the complement-fixation test was negative. January 10, 1917, my notes 
read, "No discharge now. Vesicles feel hard and sclerosed, prostate 
much smaller than at first. Secretion expressed by massage shows only a 
few pus-cells." He was allowed to marry. 



Ii8 AN OUTLINE OF GENITO-URINARY SURGERY 

Chronic Non-specific Prostatitis and Vesiculitis. — ^Another 
type of infection of prostate and vesicles is non-specific in 
character. This may be the result of a gonococcus infec- 
tion from which all the gonococci have died out, or may oc- 
cur in individuals who have never had gonorrhea. Chronic 
prostatitis and vesiculitis of non-specific origin are by no 
means rare, as they give the same symptoms and require the 
same treatment as the prostatitis occurring as a late sequel to 
gonorrhea. The two will be described together. 

The symptoms are of two kinds — sexual and urinary. The 
sexual symptoms take the form of irritability of the sexual 
reflex — i. e., premature ejaculation and nocturnal emissions, 
or at a more advanced stage, of sexual impotence. There 
will be inability to have an erection, associated very prob- 
ably with an increased mental appetite for intercourse. 
The urinary symptoms consist of frequent desire to urinate, 
urgency, and burning micturition. 

C. W. H. Aged twenty-four. Single. First seen January 24, 1916. 
Complaint: Occasional attacks of frequent, burning urination. Pre- 
mature ejaculation. Slight gleet. Denies venereal infection. His 
trouble began two years ago, when, although he had not been exposed, 
he developed a slight grayish urethral discharge which lasted some six 
weeks. Examination showed clear urine, no sugar or albumin. Sedi- 
ment: a few pus-cells. No stricture. Meatus size 22 French. Prostate 
soft. Vesicles cord-like and knotted, extending across the rectum like 
a hammock. Massage brought forth much flaky detritus, which showed 
rare spermatozoa and no pus. Meatotomy was done, after which the 
posterior urethra was dilated with sounds and the KoUmann dilator. 
The vesicles were massaged once a week, and great quantities of secretion 
were expressed. In three months his symptoms were definitely relieved 
and he stopped treatment. 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 119 

This seemed to me a case of long-standing non-specific 
vesiculitis. The vesicles showed the end-results of infec- 
tion, but required the stimulus of massage to enable them to 
clear themselves of inspissated secretion. There was a con- 
tracture of the bladder neck, due to the same process. 

Both sexual and urinary symptoms are due to the effect 
which long-continued infection of prostate or vesicles has had 
upon the mucous membrane of the posterior urethra, and par- 
ticularly of that which covers the verumontanum. Conse- 
quently, treatment must be directed toward removing that 
cause — the prostatitis or vesiculitis — by massage, and also 
to rejuvenating the urethral epithelium. 

Twice a week, every five days, or once a week, according 
to economic and pathologic conditions, the patient must pre- 
sent himself for massage. All cases cannot be treated alike; 
here, again, one must tread gently and avoid making a bad 
matter worse. One must keep in mind the thing he wishes 
to accomplish, and must with every treatment ask himself 
what he is trying to do. Massage expresses from such ducts 
as are open the retained pathologic secretions; it also increases 
the blood-supply to areas of exudate, thereby hastening the 
absorption of the inflammatory tissue. If these areas are 
rudely broken up, or if septic products pent up in closed cavi- 
ties are squeezed too vigorously, the infection is spread. 

Rough massage is followed in a few days by greater in- 
duration and by signs of infection in the urethra; gentle, per- 
sistent rubbing, which should not hurt the patient, is followed 
by gradual disappearance of the exudate and by the resump- 



I20 AN OUTLINE OF GENITO-URINARY SURGERY 

tion on the part of the prostatic tissue of a natural elasticity. 
When starting such a course of treatment the patient should 
be told that it may extend over a period of from six months 
to two years. The product of years of infection cannot be 
removed in a couple of months. 

In regard to the urethral epithelium nothing seems to 
work better than silver nitrate. It may be instilled into the 
posterior urethra through the Keyes instillator — 15 drops of 
10 per cent, silver nitrate at a time — or may be applied by an 
applicator through an endoscope directly to the verumonta- 
num. In my hands the former method has proved the 
more satisfactory. 

The urinary symptoms also may be caused by a stiffness 
of the bladder neck, due to infiltration, which allows the urine 
to trickle into the posterior urethra and excite the urinary 
reflex. For this condition one must practice dilatation with 
sounds or with the KoUmann dilator. 

These three measures, therefore — dilatation, stimulation 
with silver nitrate, and massage — are to be relied upon in the 
treatment of chronic prostatitis and vesiculitis. For every 
case there is a particular combination which gives the best 
results, and by cautious experimentation this combination 
must be discovered. 

Cure of Gonococcus Infections. — Patients often ask their 
doctor "Are you positive I can be cured?" It is right to an- 
swer "Yes." Every gonococcus infection, at least in the 
male, can be cured, provided the patient will come for treat- 
ment as often and as long as necessary. It is not always 



INFECTIONS OF PROSTATE AND SEMINAL VESICLES 1 21 

possible to remove all after-effects. Stricture may be incur- 
able, sclerosed vesicles cannot be given back their elasticity, 
and scarred prostates containing foci of infection cannot be 
guaranteed against outbreaks of a non-specific nature later 
in life. The gonococcus can always be eradicated. The 
unfortunate sequelae can usually be prevented; if they do 
result, they can be kept under control by occasional treat- 
ment. 

The tests of cure vary according to the nature of the in- 
fection. In simple anterior urethritis the criteria of cure are: 
absence of all discharge; perfectly clear urine, free from shreds; 
absence of infiltrated peri-urethral glands (determined by 
palpation of the urethra upon a sound) ; a soft prostate and 
vesicles with no pus in the expressed secretion. 

The complement-fixation test is of no great value here, as 
it may not be affected at all by an anterior urethritis. 

The question of cure in cases in which the prostate or 
vesicles have been involved is much less simple. In those 
favored individuals whose prostate and vesicles have not been 
shot through with infection, a short course of massage will 
suffice to restore to the infected parts their normal elasticity, 
and to clear their secretion of pus-cells. Such patients 
should be kept under observation for a couple of months, the 
urine watched for the reappearance of shreds, and the pros- 
tatic secretion examined several times for pus. If these 
conditions remain negative without treatment after the 
patient has returned to his usual habits, no further proof of 
cure is required. 



122 AN OUTLINE OF GENITO-URINARY SURGERY 

In many cases the question of cure is much more complex. 
These are the cases in whose prostates and vesicles such 
inflammatory changes have taken place that the restoration 
to normal is out of the question. After a year or two of 
massage the greater part of the exudate which at first plas- 
tered vesicles and prostate together in one mass may have 
been absorbed. Subjective symptoms have been relieved 
and discharge checked, but the secretion still contains pus, 
and the prostate and vesicles still feel scarred and thickened. 
In cases such as these one must rely to a large extent upon 
the intuition which he has gained through experience. Fail- 
ure to grow gonococci from the expressed secretion has some 
value. Their absence from smears is inconclusive. Lack 
of a fresh outbreak of urethritis upon provocation by drink- 
ing and by the application of silver nitrate to the urethra 
suggests that the infection has died out. Approximate re- 
turn to normal upon palpation points to a cure. If the pros- 
tate and vesicles are left alone for three months and at the 
end of that time show improvement rather than relapse, one 
may feel encouraged. All these data, taken together and 
weighed judicially, justify an experienced observer in de- 
claring a cure. His opinion may then be checked up by the 
complement-fixation test. If the test is definitely negative, 
he may rest easy in his decision. If it is definitely positive, 
he had better wait another three months before allowing the 
patient to marry. In the interim the patient should be under 
observation. Repeated negative findings during that period 
will justify a verdict of "cured," 



INFECTIONS OF PROSTATE AND SE^IINAL VESICLES 123 

Tuberculosis of the prostate and vesicles is rarely primary. 
A few cases of primary infection of the prostate and vesicles 
have been reported (KoU), but their occurrence is rare. 
Prostate and vesicles are usually involved secondarily to 
tuberculosis of the epididymis, and the situation is part of the 
big question of genital tuberculosis. 

Tuberculosis of the vesicles is usually symptomless; that 
of the prostate is likely to involve the mucosa of the bladder 
neck, and give symptoms of vesical irritability. A majority 
of men with even unilateral genital infection are sterile. 

Removal of prostate and vesicles has been practised, but 
in our experience the less radical method of hygienic and tu- 
berculin treatment, with removal of more easily accessible 
foci, such as the epididymes, has proved fairly satisfactory. 

Belfield. W. T.: Pus-tubes in the INIale, Trans. Amer. Urolog. Assoc, 

1909, iii, 13-23. 
Thomas, B. A., and Pancoast, H. K.: Observations on the Pathology, 

Diagnosis, and Treatment of Seminal Vesiculitis, Ann. Surg., 1914, 

Ix, 313-318. 
Smith, E. O.: Anatomy and Pathology of the Seminal Vesicles, Urologic 

and Cutaneous Rev., 1916, xx, No. 2. 
Herbst, R. H, : Seminal Vesiculitis as the Cause of Persistent Urethral 

Discharge, Jour. Amer. Med. Assoc, 1917, lx\'iii, 761-763. 
Geraghty, J. T.: Role of Seminal Vesicles in Non-gonorrheal Infec- 
tions of Posterior Urethra and Bladder, Jour. Amer. iSIed. Assoc, 

1917, Ixdii, 757. 
Squier, J. B.: Surgery of the Seminal Vesicles, Cleveland Med. Jour., 

1913, xu, 801-813. 
Saxe, G. a. DeS.: The Persistence of the Gonococcus in the Prostate, 

Trans. Amer. Urolog. Assoc, 1909, iii, 131-157. 
KoLL, I. S.: Primary Tuberculosis of the Prostate Gland, Ann. Surg., 

1915, Ixii, 473-475. 
Barney, J. D.: Tuberculosisof the Epididymis: Its Effect Upon Testicle 

and Prostate, Boston Med. and Surg. Jour., 1913, clxviii, 923-927. 



CHAPTER X 

PROSTATIC OBSTRUCTION " 

In men the common causes of obstruction at the bladder 
neck are nerve lesions, especially those of tabes; tumor with 
a ball-valve action; stone in the urethra; contracture of the 
bladder neck; carcinoma of the prostate, and benign enlarge- 
ment of the prostate. Of these causes, the last is by far the 
most frequent. 

Benign enlargement of the prostate, erroneously called 
"hypertrophy," is due to the formation within the gland of 
definite adenomatous masses. These consist of glandular 
and connective tissue, surrounded by a capsule of the latter. 
They can be shelled out in the same way as fibroids of the 
uterus, and except for the glandular element in their make-up 
might well be compared with uterine fibromata. The cause 
of their formation is unknown. The best preventive seems 
to be infection of the prostate a number of years before the 
age at which adenomata begin to form. Prostates scarred 
by chronic infection seem less liable to adenomatous change. 
These changes seldom are enough to give symptoms before 
the age of forty-five, and usually not before the age of fifty. 

Adenomata occur in the lateral lobes, the median lobe, 
and occasionally in the glands of the trigone. They never 

1*4 



PROSTATIC OBSTRUCTION 1 25 

take place in the posterior lobe, which seems to be reserved as 
the starting-point for cancer (Boyd and Geraghty). 

The growth of adenomata in the lateral and median lobes 
may form a horseshoe-shaped collar upon three sides of the 
bladder neck. This raises the urethral orifice above the base 
of the bladder, thereby preventing complete emptying. Or 
the lateral lobes alone may become enlarged and by jutting 
into the posterior urethra may hinder the outflow of urine. 
Occasionally a single pedunculated mass springing from the 
trigone or from the edge of the urethra may cause much ob- 
struction by its ball- valve action. 

Symptoms. — First Stage. — In the early stage of prostatic 
enlargement, before the obstruction is enough to cause trouble, 
there occurs a period of indefinite length characterized by con- 
gestion of the prostate. The investing mucous membrane is 
intensely congested and may bleed without any provocation. 
The patient has urinary frequency, especially at night, al- 
though he may pass but a very little urine at a time. The 
flow of urine may be interfered with, the act of micturi- 
tion-requiring a conscious effort at expulsion, and being 
followed by dribbling. During this stage there is likely 
to be a small amount of residual urine, perhaps i or 2 
ounces. 

The amount of congestion waxes and wanes according to 
the beha\dor and general condition of the individual. Ex- 
cesses of all kinds — overfatigue, exposure to cold — affect the 
prostate of this type. The symptoms of irritability may dis- 
appear, but the amount of residual seldom recedes. 



126 AN OUTLINE OF GENITO-URINARY SURGERY 

Prostatic Enlargement. — First Stage. — D. P. K., a lawyer eighty-four 
years of age, was referred to me in February, 1917, because of urinary fre- 
quency and hematuria. He had never had urinary trouble before, except 
that for the past few years he had found it necessary to get up two or three 
times at night. He had had an attack of angina pectoris a short while 
before, but otherwise has always been well. 

For two or three days he had been having irritability of the bladder, 
gradually increasing. When I saw him he was unable to control his 
sphincter perfectly, and there was some leakage of urine. The urine 
contained blood-cells, a rare cast, no pus, no sugar. Specific gravity 
1020. Reaction acid. Reflexes were normal. By rectum, the prostate 
felt soft, elastic, not markedly enlarged. He was kept indoors, given 
forced fluids, a diet free from meat and spices, potassium citrate, 10 
grains, three times a day, and 10 minims of sandalwood oil with each 
meal. His symptoms rapidly disappeared. In two days the urine be- 
came free from blood. February 24th he was catheterized with a small 
soft-rubber catheter. One ounce of residuum was obtained. Although 
the catheter passed easily, there was slight bleeding from the bladder 
neck. A few days after this he again had frequency, and the urine 
showed blood-cells and colon bacilli. He was put on hexamethylenamin, 
30 grains per day, and five days later reported that he felt as well as he 
had before his upset. The urine was clear, with no albumin and only a 
rare epithelial cell in the sediment. 

Since that time (one year ago) he has been well. If the urine becomes 
too concentrated or he becomes chilled, urination will become frequent 
and his urine "hot." He rests, drinks water freely, takes a few capsules 
of sandalwood oil, and the symptoms disappear. 

Second Stage. — Usually the residual urine increases; a larger 
and larger amount of urine is left in the bladder. If uninfected, 
the residuum may gradually reach such an amount that the 
bladder becomes palpable above the pubes. I have seen the 
bladder distended to the umbilicus without the patient's be- 
ing aware of his condition. Small amounts of urine are passed 
frequently, but are not enough to keep ahead of the amount 
secreted. Such a bladder is called an "overflow bladder." 
The distention may increase so gradually that no distress is 



PROSTATIC OBSTRUCTION 



127 



felt; the muscle-fibers of the bladder wall at first hypertrophy, 
later become stretched and atonic from the constant pressure. 
The ureters and renal pelves become dilated, the renal cortex 




Fig. 24.— Drawing of bladder removed at autopsy, showing adeno- 
matous changes in the prostate and resulting thickening and trabecula- 
tion of the bladder wall. 

thinned. It may be that the first symptoms to attract the 
patient's attention will be those of uremia, manifested by 
digestive disturbance and loss of weight. 



128 AN OUTLINE OF GENITO-URINARY SURGERY 

In an infected bladder the residual urine seldom reaches 
this point without giving symptoms enough to send the map 
to the doctor. An infected bladder which carries a residuum 
of 6 ounces or more is likely to cause much frequency and 
rapidly increasing difficulty in urination, due to the added 
congestion of the gland caused by the infection. The patient 
shows evidence of septic absorption — loss of weight, fever, 
malaise, and a dry, dirty tongue, bright red at the tip and 
sides. Infection is easily carried up the dilated ureters to 
the kidneys, thereby adding to the damage already caused by 
back-pressure. 

In cases with considerable residual urine, uninfected as 
well as infected, acute retention may occur at any time. 
Suffering then becomes intense. This is the third phase of 
prostatic enlargement. 

The treatment of the three phases — (i) congestion, (2) 
partial retention, (3) complete retention — will be considered 
later. 

Diagnosis of benign enlargement of the prostate can gen- 
erally be made by a consideration of the age of the patient, 
his story, and the condition of the prostate as determined by 
rectal examination. 

The age — fifty or more. If he is below forty-five, one 
should entertain with skepticism the theory that benign en- 
largement accounts for his troubles. The insidious onset of 
bladder irritability, especially at night, the increasing diffi- 
culty in expressing the urine, the dribbling after urination, 
are typical symptoms. If a clear urine accompanies these 



PROSTATIC OBSTRUCTION 129 

symptoms the difficulty will not be due to stricture. The 
urine of stricture always shows shreds. If one suspects 
stricture, it can be definitely ruled out by passing a bougie a 
boule to the cut-ojff muscle. 

Upon rectal examination the prostate should feel defi- 
nitely thickened. It may be of the large, smooth, rounded, 
elastic type, or may be divided into the two lobes and give 
an impression of thickness rather than actually project into 
the rectum. It is easy to mistake the base of a distended 
bladder for a very large, soft prostate. An adenomatous 
prostate must be separated by a sulcus from the pelvic wall. 
The enlargement begins about J inch above the anal sphincter; 
if there is a hard area in the middle line extending toward the 
sphincter, one should suspect cancer. 

The diagnosis between carcinoma and benign enlargement 
of the prostate is at times very difficult. The manner of 
onset of the trouble may be of some significance. Adenoma 
of the prostate comes on insidiously, beginning with nocturia; 
the symptoms are at first not very insistent and tend to be 
aggravated by such factors as cold weather and driving. 
The patient often says he had noticed a little trouble for quite 
a long time — a year or more, perhaps — ^before he felt the 
necessity of consulting a doctor. Carcinoma gives a briefer 
history, and its demands are more peremptory. In benign 
enlargement urination may be difficult, but is not, as a rule, 
especially painful. In cancer it is more painful, but not so 
difficult. Pains in the back and along the course of the 
great sciatic nerve are always suggestive of carcinoma. 
9 



130 AN OUTLINE OF GENITO-URINARY SURGERY 

The real factor in the differential diagnosis is the way the 
prostate feels upon rectal palpation. Advanced carcinoma 
is easy to detect. The prostate and vesicles are of stony 
consistency, densely adherent to the pelvic wall. The sur- 
face is hob-nailed, with small round nodules lying upon the 
rectal aspect. In early cases there may be only a small area 
of typical stony hardness, and even this may be masked by 
softer overlying tissue. The most difficult differentiation lies 
between the small, hard prostate in which fibrous changes 
predominate over the adenomatous, and the malignant pros- 
tate. 

Upon catheterization the adenomatous prostate shows an 
increase in urethral length. The catheter has to travel far- 
ther before it strikes urine. There is not a tremendous 
amount of pain on catheterization unless there is acute reten- 
tion and much congestion. In cancer the posterior urethra is 
exquisitely tender, and the catheter seems gripped at that 
point. Bleeding is easily induced in both. 

A few adenomatous prostates produce an amount of ob- 
struction entirely out of proportion to their enlargement as 
determined by rectal palpation. In these cases the obstruc- 
tion is usually caused by a middle lobe of the pedunculated 
type. Other prostates which by rectum feel huge, may hardly 
obstruct at all. The answer to the question of obstruction 
can be determined with certainty only by catheterization and 
measurement of the residuum. 

The diagnosis between obstruction due to prostatic changes 
and that caused by tabes dorsalis may not be easy. In 



PROSTATIC OBSTRUCTION 131 

occasional instances both conditions exist at the same time. 
In the case of every suspected prostatic, examination should 
be made of the pupillary reaction to light, of the patellar and 
ankle reflexes, and of Romberg's sign (inability to stand with- 
out swaying while the eyes are shut). If these tests are all 
negative, the chances of the condition being due to tabes are 
very, very small. Yet involvement of the vesical reflex may 
be the only sign of tabes; this fact is illustrated by the follow- 
ing case: 

Retention Due to Tabes Dorsalis. — August 24, 1917, I was called in 
consultation to see D, M. H., who had been having attacks of acute re- 
tention. He was a banker, forty-seven years of age, married, with two 
healthy children. Twenty years before he had had gonorrhea and 
syphilis, the latter treated for one and a half years with mercury pills. 
Three months ago he began to have to strain to pass urine. Had no 
nocturia. On July 28th he was catheterized and 2 quarts of urine were 
removed. Since then he has been catheterized a number of times at ir- 
regular intervals. During the preceding three weeks he had been cath- 
eterized four times. 

Examination showed a spare, healthy appearing man. Pupils reacted 
and were equal. Knee-jerks were lively. Rectal palpation: small, soft 
prostate. Urine was clear. Residuum, 10 ounces. Cystoscopy August 
25th showed a clean, slightly trabeculated bladder. Ureteral orifices not 
remarkable. Prostate not enlarged. Bladder neck not tight. The 
next day the residuum was 2 ounces. Metal catheter passed easily. 
Blood showed a strongly positive Wassermann. 

He was carefully examined by a neurologist, who could find no ab- 
normahty whatever in any of his reflexes. Spinal fluid showed 20 cells 
per cubic millimeter, increased protein content, and a strongly positive 
Wassermann test. 

August 31st he had no residuum and was voiding easily. He was put 
under the care of a neurologist and returned to his home in the West. 

Tabetic retention is characterized by an insensitiveness 
of the bladder. Thus an infected residuum which in a pros- 



132 AN OUTLINE OF GENITO-URINARY SURGERY 

tatic would cause great frequency passes unnoticed in a ta- 
betic. Not infrequently a tabetic presents himself with a 
history of incontinence. Examination shows a bladder dis- 
tended beyond belief, yet not causing any discomfort at all. 
Management of Prostatics. — First Stage. — ^Treatment dur- 
ing the period of prostatic irritability, before actual obstruc- 
tion has developed, must be directed against the congestion 
of the prostate and toward the relief of symptoms. At the 
first examination one should be able to tell, from rectal pal- 
pation and suprapubic percussion, whether or not there is a 
large amount of residual urine. A residuum of more than 8 
ounces gives a feeling of fulness upon rectal examination, 
particularly when counterpressure is made upon the lower 
abdomen. When the lower abdomen is percussed dulness 
denotes the size of the bladder. If there is no evidence of 
any considerable residual urine, measures should be instituted 
against the congestion of the prostate gland. As Keyes 
very aptly puts it, "The prostatic man resembles the men- 
struating woman in that any exposure or overdoing reacts 
promptly upon his pelvic organs." There must be a vigor- 
ous curtailment of daily activities. Overeating, overwork- 
ing, worrying, must, as far as possible, be interdicted. Alco- 
hol, except for an occasional small glass of wine with dinner, 
must be left alone. Peppery, spicy foods had better not be 
taken during the time when the congestion is most acute. 
Exposure to cold is especially to be avoided. For positive 
treatment one should give potassium citrate and sandalwood 
oil internally. The amount of water ingested should be not 



PROSTATIC OBSTRUCTION 133 

less than 80 ounces a day, and may well be more. Rectal 
injections of very hot water once a day are soothing, and 
so are hot sitz-baths. Gentle prostatic massage may be 
tried. 

As a rule, the symptoms of irritability will quiet down to 
a large extent upon confinement to the house, the ingestion 
of plenty of water, and the use of sandalwood oil. Until 
they quiet down one should not attempt to determine the 
exact amount of residual urine. After they have subsided, 
however, it is best to find out how much obstruction exists. 
Upon the answer to this question the future management of 
the case depends. The residual urine is drawn with a soft- 
rubber catheter or a coude woven catheter, passed with the 
utmost gentleness. The bladder should be left full of boric 
acid solution. If the residual urine is less than 2 ounces, 
and uninfected, it may be disregarded. The only indication 
for prostatectomy, as a rule, is mechanical obstruction; very 
occasionally the repeated hemorrhages may require radical 
measures. 

Second Stage. — If the residuum is more than 2 ounces, the 
question of operation should be considered. A residual urine 
of that amount is sure to increase within a very few years. If 
the patient is in good condition, the likelihood of his requir- 
ing operation later may make it advisable to forestall the 
mishaps which may intervene, and do it now. If his years 
are already numbered, he may be allowed to go on, being seen 
occasionally and his residual urine kept track of. 

The amount of obstruction caused by the prostate will 



134 AN OUTLINE OF GENITO-URINARY SURGERY 

vary somewhat with variations in the extent of congestion of 
the gland. When an attack of acute congestion subsides 
conditions may return nearly to normal, and remain so until 
cold weather, overwork, automobiling, or some such factor 
again engorges the gland and causes it to obstruct. 

If the amount of residual urine is habitually enough to 
cause back pressure upon the kidneys, the welfare of the 
patient demands its renToval. If the bladder is infected, 
catheterization and lavage will improve rather than augment 
the irritation. If it is uninfected, catheterization should be 
undertaken only after careful consideration of the circum- 
stances surrounding that particular case, and after a probable 
course of action has been mapped out. Catheterization, no 
matter how carefully done, may set up an acute infection. 
One should decide whether, assuming an important amount 
of residuum exists, the situation should be met by regular 
catheterization or by operation. My own feeling would be 
that more than 6 ounces of residual urine, in an uninfected 
bladder, demands one or the other of these measures. If in- 
fection already exists, half that amount of residuum is an 
indication for interference. 

Shall this interference be operative, or shall it be by 
catheter? Upon this point it is well to take into considera- 
tion the general condition of the patient and his economic as 
well as his physical circumstances. A retired business man, 
fretting because he has nothing to do, will take vastly more 
interest in seeing that he catheterizes himself regularly and 
properly than will a laboring man still dependent upon his 



PROSTATIC OBSTRUCTION 135 

earnings. Of course, the question in any particular case 
may be settled by the difficulty of catheterization. The 
passage of instruments may become so painful or so difficult 
that other ways of meeting the situation will have to be 
sought. 

There is no valid argument against operation except such 
a general break-do\vTi that the end seems in view. Even 
then, through preliminary bladder drainage, the patient may 
so improve that he presents an altogether different problem. 
Dependence upon the catheter is a poor substitute for pros- 
tatectomy. The urinary tract will certainly become infected. 
At any time swelling of the prostate may require surgery for 
its relief. The troubles inherent to catheter life are many. 
It is a poor make-shift. 

If a patient is to live a catheter life he should be carefully 
instructed in regard to all its details. Soft-rubber catheters 
of as large a size as will pass easily should be used, though 
woven catheters may be necessary. The former should be 
rinsed out with running water after use, and once a day 
enough catheters to carry the patient through the next 
twenty-four hours should be boiled and put aside in a clean 
towel. Woven catheters should be carefully washed, inside 
and out, and kept in a flat, covered container full of boric 
acid solution or in a clean towel. Before catheterizing him- 
self the patient must wash his hands. It is desirable, though 
not essential, that once a day he should wash his bladder, 
which may be done easily with a fountain syringe, the hard- 
rubber tip replaced by a glass nozzle. As a rule, boric acid 



136 AN OUTLINE OF GENITO-URINARY SURGERY 

(2 per cent.) should be used, and is prepared by mixing, equal 
parts of a saturated solution and warm water. ^ 

There are comparatively few cases in which operation, 
properly done, will not offer a fair chance of recovery. Age 
in itself is not a contraindication. I have seen men ninety 
years of age go through operation without being really sick 
at all. Kidneys so damaged that their phthalein output is 
less than 5 per cent, in one hour have not prevented good re- 
covery. Disease of the circulatory system, unless far ad- 
vanced, is not a contraindication to operation, for spinal 
anesthesia puts practically no strain upon the heart. 

Third Stage. — ^At any time an enlarged prostate may swell 
and obstruct the urinary passage. The obstruction is sel- 
dom absolutely complete; a few drams may be passed at a 
time, but the outflow cannot keep pace with the inflow. The 
bladder distends. Its walls become stretched beyond the 
limits of their elasticity. If this condition endures for many 
days, uremic poisoning will set in, manifested first by urinous 
breath, soft distention, anorexia, nausea and vomiting, later 
by coma. 

When a patient is first seen with retention, one must de- 
cide whether operation is to be done at once or whether 
catheterization should be tried. 

My own feeling is that immediate operation, by which I 

1 The saturated solution is made by placing from 4 to 8 ounces of 
boric acid crystals in a 2-quart glass bottle. The bottle is then filled with 
boiled water. When this stock gets low, more water is added. So long 
as there are crystals at the bottom of the bottle, the solution is saturated 
(4 per cent.). 



PROSTATIC OBSTRUCTION 137 

mean preliminary drainage of the bladder under local anes- 
thesia, and not prostatectomy, should be done in practically 
every case. In the first place, once a patient has acute re- 
tention due to the prostate, he will never be able to empty 
his bladder again. If the patient's situation necessitates a 
delay of several hours before he can be got to a hospital, 
catheterization or suprapubic tapping of the bladder should 
be done. 

I know of no operation in which the patient needs so much 
the daily attention of his surgeon as in prostatectomy. For 
this reason prostatectomy should almost never be done ''out 
of to^^^l." The actual operation is less important than con- 
stant supervision during the postoperative period by a man 
trained in the management of such cases. 

In regard to the immediate treatment of acute retention 
there is considerable difference of opinion. All geni to-urinary 
surgeons agree that immediate prostatectomy must not be 
done. To remove the prostate in the face of a distended 
bladder is little short of murder. Preliminary drainage is 
essential. Some prefer to carry out this drainage by use of 
the indwelling catheter. Others believe that free suprapubic 
drainage gives better results. Personally, I prefer the latter 
method. I believe the drainage is better, infection of the 
prostate is reduced rather than augmented, and the supra- 
pubic wound is given a chance to become thoroughly walled 
off before the removal of the prostate. The chances of hav- 
ing the drainage get out of order, with resulting back-pressure, 
are infinitely less. 



138 AN OUTLINE OF GENITO-URINARY SURGERY 

Cystotomy. — ^The operation of cystotomy^ is preceded by 
infiltration with J per cent, novocain of the skin and subcu- 
taneous tissues of the suprapubic region. An area 3 inches 
wide, extending from pubes almost to umbilicus, is thoroughly 




Fig. 25. — Area to be infiltrated in suprapubic cystotomy under local 
anesthesia. 



infiltrated. The point of the needle is then pressed inward 
until it is felt to pass through the aponeurosis of the rectus 



* I am indebted to Dr. Arthur L. Chute for this technic. I have found 
it always satisfactory. 



PROSTATIC OBSTRUCTION 



139 



muscle. More novocain is injected under the aponeurosis 
and into the prevesical space. One should wait ten minutes 
before starting the operation. A median incision about 3 
inches long is then made, the lower end being i inch above 
the pubic bone. The aponeurosis is divided and the recti 




Fig. 26. — Suprapubic cystotomy. Peritoneum stripped upward to expose 
bladder. Stay sutures placed and bladder wall incised between them. 

separated. The peritoneum is stripped up from the front of 
the bladder, and that viscus is opened enough to admit the 
finger. Digital exploration will show the presence of tumor, 
stone, or diverticulum, and will give definite information as 



140 AN OUTLINE OF GENITO-URINARY SURGERY 

to the condition of the prostate. A rubber tube J inch in 
diameter is inserted, the edges of the bladder incision are 
drawn against the abdominal wall by two sutures fastened 

' ■ ' -" <j7:r^ 



..]> 





Fig. 27.^Suprapubic cystotomy. Rubber tube has been inserted into 
bladder and rectus fascia sutured. Stay sutures now put through skin 
on either side and tied loosely, so that opening into bladder can be easily 
found if necessary. 

loosely to the fascia or skin, rubber tissue wicks are placed to 
the prevesical space, and the incision closed about the tube. 
A right-angled glass tube is placed in the bladder tube and the 
urine drained into a bottle. This drainage apparatus re- 



PROSTATIC OBSTRUCTION 141 

quires very little attention, and the patient can be kept 
perfectly dry. The drainage can be continued as long as 
necessary. Sometimes three months may elapse before a 
patient is in proper condition for the removal of the prostate. 
During this period the one most essential measure is the fore- 




Fig. 28. — Paracentesis of overdistended bladder. Note how peri- 
toneum is carried upward by bladder, and note also the direction in which 
the trocar is inserted. 

ing of fluids. The twenty-four hours' output of urine should 
never fall below too ounces. 

A modified form of suprapubic cystotomy, which may be use- 
ful in case the above operation cannot be carried out and 
catheterization is deemed unwise, consists in puncturing the 



142 AN OUTLINE OF GENITO-URINARY SURGERY 

bladder above the pubes with a trocar the diameter of which 
is about the same as that of a 24 French sound, and through 
the trocar inserting a Pezzer or mushroom catheter into the 
bladder. This can be done without fear of entering the 
peritoneum only in case the bladder is greatly distended. 
Such bladders carry the vesical fold of peritoneum up with 
them, and the bladder wall just above the pubes lies directly 
beneath the recti muscles. The area involved should be in- 
filtrated with novocain, the skin punctured with a knife, and 
the trocar inserted about an inch above the pubes, with its 
tip pointed toward the bifurcation of the aorta. If it is in- 
serted perpendicularly to the table upon which the patient 
is lying, the hole in the bladder will be made too near the 
urethral orifice, and will be carried down still farther as the 
bladder contracts down after it is emptied. 

If these operations cannot be done because of lack of oper- 
ative facilities, catheterization may be tried. Select the 
catheter which seems most likely to enter. Don't lead up to 
it gradually by trying the less likely ones first. A woven 
catheter with bougie tip bent at an angle is an excellent in- 
strument. So are the coude and bi-coude catheters, also 
woven. At times nothing succeeds like an old-fashioned 
metal catheter with prostatic curve, but the objection to it is 
that it is not a good instrument to leave in the urethra (Fig. 
29, 3). A soft-rubber catheter upon a stylet bent into a 
"prostatic curve" is very useful, especially if the catheter is 
to be fastened in the urethra. 

Very gently the catheter, well lubricated, is passed into the 



PROSTATIC OBSTRUCTION 



143 



prostatic urethra. If gentle pressure does not cause it to 
enter the bladder, its point may be twisted from side to side 
in an attempt to find the passage. Force must not be used. 
If catheter No. i will not pass easily, try a different t}^e. If 
the bleeding is profuse, give up the attempt. Do not exhaust 
the patient by your endeavors. It is far better to tap the 
bladder above the pubes than to tear the prostate and set up 




Fig. 29. — Prostatic catheters. 1. Bougie tip coude. 2. Bi-coude. 3. 
Silver catheter with prostatic curve. 

an acute infection. In tapping, be careful to enter just above 
the pubic bone and point the needle toward the bifurcation of 
the aorta. If the catheter does enter the bladder, do not let 
your sense of satisfaction, which, egged on by the relief of the 
patient and the admiration of the family, may be consider- 
able, lead you to empty the entire bladderful of urine. No 
more than 20 ounces should be drawn off at first ; the catheter 



144 AN OUTLINE OF GENITO-URINARY SURGERY 

should then be fastened in with strips of adhesive plaster and 
snapped or tied off. Every hour lo ounces more may be 
withdrawn. After twenty-four hours or so the bladder will 
be emptied and the drainage may be allowed to run con- 
stantly (Figs. 30-34). 




Fig. 30. — Catheter in urethra. Three longitudinal strips of adhesive 

plaster. 

The danger from sudden emptying of an overdistended 
bladder is great. The wall, stretched until its elasticity is 
lost, collapses like a wet paper bag. Intense congestion 
results not only in the bladder wall but in the ureters and 
pelves as well. Some overdistended vein bursts, and a hemor- 
rhage sufficient to fill the bladder with clots is the result. 



PROSTATIC OBSTRUCTION 



145 



When this happens, suprapubic cystotomy must be done. 
When an overdistended bladder is emptied by suprapubic 
cystotomy these phenomena do not occur. There is no 
danger in suddenly emptying the bladder when it is opened. 
If the bladder drains well, the catheter may be left in for 
from three days to a week. The patient is given hexamethyl- 




Fig. 31. — The three longitudinal strips fastened to penis by circular 
band of adhesive plaster. Catheter adjusted. Two of the strips being 
stuck on to catheter. 



enamin, gr. xv t. i. d., forced fluids, and is encouraged to sit 
up in a reclining chair. When the urinary output has fallen 
from the large amount following retention to a more or less 
steady level, and the patient shows no evidence of uremia or 
septic absorption, the catheter may be removed and inter- 
mittent catheterization substituted. The patient may be 



146 AN OUTLINE OF GENlTO-URINARY SURGERY 

able to void spontaneously, but only a small proportion of his 
urine will be thus passed. He will have to depend upon the 
catheter (unless he submits to operation) for the rest of his 
life. 




Fig. 32. — Strips of adhesive plaster, after adjustment of catheter, are 
fastened securely in place by a circular ligature of silk or strong thread 
tied close to meatus. 

Prostatectomy. — ^As a result of preliminary drainage, 
whether by suprapubic tube or by urethral catheter, the kid- 
neys gradually recover from the effects of back-pressure until 
they reach a fairly stable condition. The time required for 
this will vary from ten days to three months. In most in- 
stances from two to three weeks will suffice. The condition 
then attained may be far below normal, but if the kidneys 
are able to carry off waste products to such a degree that the 



PROSTATIC OBSTRUCTION 



147 



patient's appetite and strength improve they will carry him 
through prostatectomy provided they are subjected to no 
additional strain. For this reason the choice of anesthetic is 
all important. Ether is distinctly bad. Gas-oxygen spares 
the kidneys and is, by some surgeons, considered the best 
anesthetic. Spinal anesthesia seems to m.e by all means the 







^ 



Fig. 33. — Cross-section of adenomatous prostate at level of veru- 
montanum. Note how well defined is the line of cleavage between the 
lateral lobes and the posterior lobe. 



safest method. If given by one familiar with the technic, it 
is, in my belief, devoid of danger. It places no strain upon 
the kidneys, and affects the heart only through the fall in 
blood-pressure which it not infrequently causes. Ten eg. of 
novocain and adrenalin dissolved in 2 c.c. of water and diluted 
with an equal part of spinal fluid are injected very slowly be- 
tween the second and third or third and fourth lumbar ver- 



148 AN OUTLINE OF GENITO-URINARY SURGERY 

tebrae. The anesthesia lasts from an hour and a half to two 
hours. Within the past two years I have not seen it fail to 
produce anesthesia one single time. In very nervous people 
a few whiffs of ether may be needed for the psychic effect. 




Fig. 34. — For additional security longitudinal strips are bound to 
catheter by spiral strip. 

Only enough is given to draw the patient's attention away 
from the operation. 

If preliminary drainage has been by urethral catheter, the 
bladder must be opened. A median suprapubic incision 



PROSTATIC OBSTRUCTION 149 

long enough to admit two fingers into the bladder is made. 
If suprapubic cystotomy has already been done, the fis- 
tula must be dilated to admit the forefinger. Enuclea- 
tion of the adenomatous masses from the prostatic cap- 
sule by the suprapubic route is done by inserting the finger 
into the prostatic urethra, hooking it around the anterior 
end of one lobe, and cracking the mucous membrane along 
the line where this lobe meets the lateral urethral wall. The 
line of cleavage thus opened up is followed by the finger, 
and the adenomatous lobe is turned out of its bed. The 
other lobe is removed in the same way, and smaller adenomata 
beneath the bladder neck are likewise enucleated. When all 
masses are removed, the anterior half of the floor of the pos- 
terior urethra, bearing the verumontanum and ejaculatory 
ducts, is found to be intact. Behind this the urethra has 
been stripped of its mucosa, and consists of a raw, oozing 
cavity. Posteriorly this ca\dty is bounded by the internal 
vesical sphincter, which can be clearly felt. 

The hemorrhage from this denuded area may be consider- 
able. The ooze is easily controlled; the only important bleed- 
ing comes from torn vessels at the bladder outlet. To con- 
trol this bleeding various methods have been used. At the 
Mayo Clinic, Judd sutures the torn edge of the prostatic cap- 
sule. Hagner, of Washington, has suggested the use of an 
inflated rubber bag to press upon the bleeding area. The 
Hagner bag is a pear-shaped one of soft rubber, with a tube 
attached to the smafl end. A specially devised sound is 
passed through the urethra from without; over the tip of this 



I50 AN OUTLINE OF GENITO-URINARY SURGERY 

the tube is placed. As the sound is withdrawn it draws the 
tube out through the urethra. When the bag has been drawn 
into the prostatic cavity it is inflated, the tube is clamped and 
held taut. After a few hours the bag is deflated and one or 
two days later is withdrawn through the suprapubic wound. 
A catheter is sewed to the tip of the urethral tube and follows 




Fig. 35. — Drawing of bladder removed at autopsy, showing adeno- 
matous prostate and the line of cleavage which the finger follows in supra- 
pubic prostatectomy. 



the tube into the bladder. This ingenious technic works 
very satisfactorily and does check hemorrhage, provided the 
tube does not break. 

If the bladder has been drained by a suprapubic tube for 
several weeks the congestion of the prostate is usually so de- 
creased that not much bleeding follows prostatectomy. In 
the two-stage operation with which I am familiar the pros- 



PROSTATIC OBSTRUCTION 151 

tate is enucleated through the small hole from which the 
drainage-tube has been removed. Only one finger can be 
inserted; in order to make enucleation possible the prostate 
must be supported by the forefinger of the other hand in the 
rectum. Enucleation through so small an aperture is often 
difficult, but is compensated by the absence of postoperative 
suppuration and by the rapid healing of the already walled- 
off tissues. After the enucleation a catheter is passed 
through the urethra and held in place by a silk suture passed 
through its tip and fastened to the edge of the skin incision. 
If there is any bleeding worth mentioning a sponge is packed 
into the posterior urethra about the catheter. 

This second part of the two-stage method of prostatectomy, 
done under spinal anesthesia, really affects the patient very 
little. There is no cutting, and, except for the denuded 
urethra, no freshly opened surface to admit infection. The 
kidneys are not at all affected by it, for the conditions of 
bladder drainage remain the same. 

Prostatic Enlargement — Complete Retention, Overflow Bladder. — 
C. G.. a metal worker of sixtj'-nine, entered the Deaconess Hospital on 
September 17, 1917, suffering from acute retention. For nine years he 
had had more or less difl&culty in voiding. He had been through two 
attacks of swelling of the feet, but other^^•ise had always been well. For 
the past week he had been passing very small amounts of urine fre- 
quently. He was nauseated; penis, scrotum., and legs were full of edema. 
By rectum, prostate was very large and elastic. Stricture was ruled out 
by the passage of a catheter through the cut-off muscle. Reflexes were 
normal. Nothing abnormal was found in cardiac condition. Face drawn 
and pale, tongue thickly coated. Under local anesthesia the bladder was 
opened suprapubically, with escape of a very large amount of concen- 
trated, foul urine, the last of which contained thick pus. A large rubber 
tube was inserted into the bladder and the wound closed about the tube. 



152 AN OUTLINE OF GENITO-URINARY SURGERY 



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PROSTATIC OBSTRUCTION 1 53 

Fluids were forced. The patient reacted very well. His edema disap- 
peared within forty-eight hours, appetite returned, and in three weeks 
he was in condition for prostatectomy. Under spinal anesthesia large 
masses of adenomatous tissue were enucleated through the suprapubic 
fistula. A catheter was passed through the urethra and fastened to the 
edge of the suprapubic wound with a silk suture. There was slight ooz- 
ing, and a sponge was packed into the prostatic cavdty. This was re- 
moved two daj'S later. In the second week epididymitis developed, but 
quieted down with support and hot flaxseed poultices. The catheter 
was removed 23 days after operation. The wound broke open, however, 




Fig. 37. — Cystoscopic picture in a case of enlarged prostate. The 
dark area is a portion of the prostate projecting into the bladder. In the 
background is seen the trabeculated bladder wall. 



necessitating the replacing of the catheter. After the wound had 
firmly healed it was found that there was a residuum of 16 ounces. Cys- 
toscopy showed no cause for this except a flabby bladder. A 32 French 
sound passed easily. The bladder was irrigated daily with potassium 
permanganate solution, and when the patient left the hospital on Novem- 
ber 29, 1917, after a stay of ten weeks, he had only 3 ounces residuum. 
He came to my office every week for irrigation. The residuum decreased 
somewhat, so that when last seen he had between 1 and 2 ounces only, and 
felt perfectly well. He got up only once at night, his feet no longer 
swelled, and his general condition was excellent. 



154 AN OUTLINE OF GENITO-URINARY SURGERY 

The perineal route is favored by some operators, who use 
it altogether. Unquestionably it is less shocking to the 
patient. The wound is smaller. The chief drawback is, in 
my experience, the tightness of the bladder neck which occa- 
sionally follows. A diaphragm is sometimes left at the in- 
ternal orifice, which prevents a perfect functional result. 
There is some danger of interfering with the control of urina- 
tion, and a bare possibility of getting a recto-urethral fistula. 

For certain types of cases it is the operation of choice. 
Men with fat abdomens, in whom, in order to permit supra- 
pubic enucleation, a large wound would have to be made, are 
best done by the perineal route. The small fibrous prostate, 
which cannot be enucleated by the finger, can be dissected 
out through a perineal incision and the bladder neck widely 
opened. 

The operation is best done through a curved pre-anal in- 
cision. The central tendon of the perineum is cut, allowing 
the rectum to fall back. The rectal aspect of the prostate 
is exposed, an incision made into the urethra at the apex of 
the prostate, and the gland drawn down by Young's tractor. 
The lobes may be enucleated through incisions made through 
the posterior capsule or may be enucleated through the 
urethra. A double-barreled tube drains the bladder through 
the perineal wound. 

J. P., age sixty-nine, a real estate dealer, was seen by me November 
9, 1917, in a condition of almost total retention. He was able to void 
small quantities of bloody urine. The bladder was distended almost to 
the umbilicus. Prostate, by rectum, was very large' /and elastic. For 
some months he had had nocturia and frequent burning urination, 



PROSTATIC OBSTRUCTION 155 

One week ago his bladder had been washed out and 1 pint of residual 
urine \^dthdra^^^l. Since that time he had been feehng miserable. 
He was a very obese man. Heart showed a systolic murmur, but there 
was no evidence of decompensation. The reflexes were normal. No- 
vember 10th, under local anesthesia, median suprapubic incision. A 
thickened bladder was opened, and, upon exploration with the finger, 
it was found that the incision had been made into a diverticulum of 
about 2 ounces capacity which was situated on top of the bladder. The 
urine was very foul. The diverticulum was dissected out and the 
stoma resected. A stone the size of a plum was removed from the 
bladder. A suprapubic tube was sutured in the bladder. 

The wound, infected by the very dirty urine, broke down, but aside 
from that convalescence was normal. By December 19th the supra- 
pubic wound had shrunken down about the tube and was well healed. 
The urine had cleared up and the patient was in good condition. 

December 19th, spinal anesthesia. It seemed clear that o'^dng to 
the patient's obesity suprapubic enucleation would be \'ery difficult. 
Perineal prostatectomy was therefore done, and two adenomatous lobes, 
each the size of a horse-chestnut, were enucleated. There were many 
small concretions of brownish color between the lobes and the cap- 
sule of the prostate. Convalescence from this operation was very good, 
except for a short attack of epididymitis, and the patient left the hos- 
pital on January 6th with less than 1 ounce residuum. 

Postoperative Treatment. — After any operation upon the 
prostate the most important thing is to keep up the output of 
urine. Unless large quantities of urine (100 ounces or more 
every twenty-four hours) are excreted the kidneys may fail 
to perform their full duty. Uremia sets in, evidenced by dry 
tongue, soft distention, anorexia. If these signs appear, the 
patient should be given salt solution under the breast, 750 c.c. 
or more at a time. Besides the effect of the fluid upon his 
kidneys, he is tremendously impressed with the unpleasant- 
ness of the procedure, and will suddenly realize the necessity 
of drinking water. A patient of mine had subpectoral salt 
solution once or t^^^ce a day for forty consecutive days before 



156 AN OUTLINE OF GENITO-URINARY SURGERY 

he regained his appetite and shook off the signs of impending 
uremia. 

Second only in importance to plenty of fluid is the matter 
of exercise. Shaky old men must be got out of bed early — 
as soon as the urine ceases to be bloody — and must be made to 
walk and go into the fresh air. Only by closest observance of 
these principles can some of these old men, whose kidneys 
are all but gone, be dragged back to health. Once they begin 
to recover, the improvement in general condition is nothing 
short of marvelous. The game is worth the candle, but only 
by the most assiduous care can it be won. 

After-treatment of Prostatectomy. — The patient discharged 
by the surgeon after a successful prostatectomy is seldom 
cured of his cystitis. If he is left untreated after his dis- 
charge from the hospital he runs an excellent chance of hav- 
ing an exacerbation of his bladder infection. This causes 
swelling of the structures about the vesical orifice, with the 
retention of a small amount of urine. This residual urine 
does not increase to more than 3 or 4 ounces, but is sufficient 
to aggravate the cystitis and to assist greatly in the forma- 
tion of bladder stone. Every case after prostatectomy should 
be seen, during the first three months, at least once every two 
weeks. The condition of the urine and the amount of resid- 
uum should be followed.. If there is residual urine or if cys- 
titis exists, the bladder should be washed frequently, and the 
patient should take either sandalwood oil, 10 minims t. i. d., 
or hexamethylenamin, 45 grains a day, with sodium acid 
phosphate, 10 grains t. i. d., if the urine is not already acid. 



PROSTATIC OBSTRUCTION 157 

Dilatation of the bladder neck with sounds improves the 
action of the sphincter and diminishes residuum. Even after 
the urine becomes free from pus the patient should be seen 
occasionally, as his bladder may be reinfected from the 
chronic pyelitis which is likely to have originated during 
his preoperative days. 

The Small Fibrous Prostate. — There is a type of obstruc- 
tion at the bladder neck caused by contraction of the in- 
ternal urethral orifice. This contraction is due to the pres- 
ence of connective tissue which has formed beneath the 
mucosa as a result of a previous inflammatory process. The 
outlet of the bladder is puckered into a tight orifice. The 
effect of this upon urination may be heightened by the deposit 
of more fibrous tissue throughout the prostate itself. The 
condition is called by various names — median bar obstruction, 
small, fibrous prostate, contracture, prostatism sans pros- 
tate. It is met in men of thirty-five years of age and up- 
ward, and may be responsible for retention of urine in amounts 
varying from i or 2 ounces up to 90 or more. Usually the 
vesical orifice grips a sound, but in many cases it will admit 
a soft-rubber catheter easily. 

The diagnosis depends upon the exclusion of other causes 
for retention, namely, diverticulum, nerve lesions, and cancer. 
Adenomatous enlargement of the prostate is ruled out by 
rectal and cystoscopic examination. 

The treatment consists of removal of the obstruction 
either by the use of Young's punch or by perineal prosta- 
totomy. The punch operation is done through the urethra 



IS8 AN OUTLINE OF GENITO-URINARY SURGERY 

and may require only local anesthesia. Improvement is apt 
to be only temporary. Prostatotomy — the excision of a seg- 
ment of the contraction ring — aided by the removal of as 
much prostatic tissue as possible, is the most satisfactory 
measure. It is done in the same way as a perineal prosta- 
tectomy, except that the obstruction is cut out instead of 
being enucleated with the finger. 

Cancer of the Prostate. — To every 5 or 6 cases of benign 
enlargement of the prostate there is i case of cancer. In the 
great majority of cases cancer of the prostate, as has been 
shown by Geraghty, originates in the posterior lobe. This 
is the area beneath the verumontanum, and is distinct from 
the so-called '^middle" lobe and lateral lobes in which adeno- 
matous changes occur. The growth extends upward along 
the seminal vesicles, and although it may appear in the 
mucous membrane of the posterior urethra and trigone, it 
is not likely to cause retention of urine until the process is 
well advanced. The symptoms are due to (i) involvement 
of sensory nerves of the posterior urethra, causing frequency; 
(2) ulceration of mucosa, causing hematuria; (3) pains in 
back and legs, due either to involvement of nerves in the 
growth or to metastases in the spine. Later in the course 
of the disease difficulty with urination is met, and a fact 
peculiar to cancer of the prostate is the unusual difficulty of 
catheterization and the undue amount of pain and bleeding 
caused by it, compared to the relatively slight obstruction 
to the outflow of urine. 

Upon rectal examination the finger strikes a hard area in 



PROSTATIC OBSTRUCTION 159 

the anterior rectal wall just inside the internal sphincter. 
This area may be knobby and plastered on to the pelvic wall, 
forming a soUd platform across the pelvis. It may be felt 
extending upward along the vesicles. It feels altogether dif- 
ferent from the smooth, elastic, well-defined adenomatous 
prostate. 

In comparative!}'- few cases adenomatous prostates undergo 
malignant degeneration. In that event, diagnosis is more 
difficult, and is based upon the presence in the adenomatous 
lobes of areas of stony hardness. As inflammation may cause 
similar areas, it is readily seen that the early diagnosis of 
such a case is a matter of considerable uncertainty. Cystos- 
copy may show a characteristic knobbing of the vesical sur- 
face of the prostate, provided the growth is in that direction. 

Prognosis. — Cancer of the prostate is of slow gro\\lh. 
!Men who, when first seen, have already weU-marked indura- 
tion of the prostate and vesicles, may live for several years 
more. Very probably their cancer had begun several years 
previously, thus covering a period of from five to eight years 
in all. I have often been surprised at the extent of the 
growth in men who have just begun to have symptoms. 
Sometimes general carcinomatosis will claim its victim be- 
fore the bladder is affected. 

Treatment. — An attempt at radical cure of cancer of the 
prostate is made by Hugh Young in his operation for total re- 
moval of prostate and seminal vesicles. Aside from the tech- 
nical difficulties of the operation one has to contend with the 
difiiculty of making a definite diagnosis of cancer while it is 



l6o AN OUTLINE OF GENITO-URINARY SURGERY 

yet early enough to attempt a radical cure. For one reason 
or another the operation has not been generally adopted. 

In cases in which obstruction to the urinary outflow exists 
the prostate may be attacked by the perineal route and as 
much as possible of the malignant tissue nibbled away. 

Within the past few years the use of radium in the treat- 
ment of carcinoma of the prostate has gained several en- 
thusiastic supporters. Hugh Young applies it by rectal and 
urethral approaches. Barringer inserts a needle containing 
a capsule of radium into the prostatic tissue by way of the 
perineum. Both have observed some very satisfactory re- 
sults, about one-third of Young's cases being definitely im- 
proved, with marked recession of the growth. 

I have tried a combination of perineal operation and radium 
treatment. After removing as much of the malignant tissue 
as possible, and restoring the patency of the bladder outlet, 
I place tubes of radium emanations in each lobe, withdrawing 
them by means of strings brought out through the perineal 
wound. Too few cases have been treated this way to justify 
any opinion as to the value of the method. 

By means of the above measures the patient with carci- 
noma of the prostate can be eased along until the ureters be- 
come obstructed by the growth, or .until general carcinoma- 
tosis takes place. As a last resort suprapubic cystotomy may 
be necessary. 

It will be five years at least before we can judge of the 
real value of radium in this condition. At present it is the 
only ray of light in an otherwise very gloomy situation. 



PROSTATIC OBSTRUCTION l6l 

Cancer of the Prostate — Perineal Prostatectomy." — D. C, a gardener 
se\^enty-four years of age, was referred to me on November 6. 1917, 
for partial retention of urine. He had always been well until a few 
months ago, when he began to notice difl&culty in passing water. This 
has increased and he has required catheterization. His doctor found a 
residuum of 16 ounces. 

Examination showed a rather feeble old man, whose reflexes and 
general physical examination were negative. By rectum, the prostate 
was of stony hardness, not much enlarged and not adherent to the pelvic 
walls. A woven catheter was passed with some dif3&culty, and fastened 
in the urethra. The bladder was drained by catheter for three days. 
The urine was only slightly infected (more characteristic of carcinoma of 
prostate than of adenomatous obstruction). 

November 9th, under ether, perineal partial prostatectomy was done, 
as much as possible of the carcinomatous gland being nibbled away. 
The growth could be felt extending upward beneath the trigone. Micro- 
scopic examination showed scirrhous carcinoma. A perineal tube was 
left in for two days, and a catheter which had been inserted at operation 
was left in for about ten days. After its removal there was leakage 
through the wound and the catheter was replaced. December 10, 1917, 
he left the hospital. The wound was healed, there was no residuum. 
April 8, 1918, he came to see me to learn if he could go to work. He 
looks and feels well. Color good; has evidently gained weight. He has 
no urinary symptoms and gets up only once at night. Urine slightly 
hazy. No residuum. No abdominal masses. By rectum, however, the 
whole base of the bladder feels indurated as high as the finger can reach. 

LowsLEY, O. S.: The Gross Anatomy of the Prostate Gland and Con- 
tiguous Structures, Trans. Amer. Urolog. Assoc, 1914, vili, 172-195. 

Cabot, H.: The Operative Treatment of Prostatic Hypertrophy, 
Lancet-Clinic, March 8, 1913. 

Squier, J. B.: Vital Statistics of Prostatectomy, Surg., Gynec, and 
Obst., October, 1913, 433-436. 

Wilson, L. B., and McGrath, B. F. : Surgical Pathology of the Prostate, 
Surg., Gynec, and Obst., December, 1911, 647-681. 

Chute, d. L.: Some Things that Influence the Mortality after Pros- 
tatectomy, Boston Med. and Surg. Jour., 1914, clxxi, 808-812. 
The Small Fibrous Prostate, Boston Med. and Surg. Jour., 1910, 
clxiii, 606-610. 

Chetwood, C. H. : Difi"erent Types of Fibrous Obstruction of the Blad- 
der Outlet and their Treatment, Surg., Gynec, and Obst., 1915, 
xxi, 202-205. 
zi 



l62 AN OUTLINE OF GENITO-URINARY SURGERY 

Smith, G. G.: Spinal Anesthesia in Urology, Interstate Med. Jour., 

1914, xxi. No. 11. Experimental and Clinical Observations on the 
Blood-pressure in Spinal Anesthesia, Boston Med. and Surg. Jour., 

1915, clxxiii, 502-504. 

Geraghty, J. T.: Pathology of Cancer of the Prostate, Reports of Meet- 
ings of N. E. Branch of the American Urological Association for 
the Winter of 1912-13. 

Barrtnger, B. S.: Radium in Treatment of Cancer of Prostate and 
Bladder, Jour. Amer. Med. Assoc, 1917, Ixviii, 1227. 

Young, H. H.: Cancer of Prostate, Ann. Surg., 1909, 1, 1144-1233. 

Young, H. H., and Frontz, W. A.: Some New Methods in the Treat- 
ment of Carcinoma of the Lower Genito-urinary Tract with Radium, 
Jour. Urology, 1917, i, 505-542. 



CHAPTER XI 

DISEASES OF SCROTUM AND TESTICLE 

Hydrocele ; Spermatocele ; Hematocele.— The testicle hangs 
in the scrotum suspended by the spermatic cord and attached 
to the scrotal wall by the reflection of the tunica vaginalis 
on to the middle third of the epididymis. Except at its at- 
tachments the testis is covered by the visceral layer of the 
serous membrane which lines the sac (tunica vaginaHs). 
Lining the cavity of the scrotum, is the parietal layer of this 
same membrane. Both are derived from the peritoneum 
during the descent of the testis. In the sac thus formed 
three kinds of fluid may accumulate. A collection of watery 
fluid is a hydrocele; of spermatic fluid, a spermatocele; of 
blood, a hematocele. 

Hydrocele fluid is usually a clear, yellow, slightly viscid 
liquid. Its composition may be changed by the addition of 
products of inflammation, such as fibrin, pus-cells, and blood. . 
Hydrocele is idiopathic — i. e., we do not know what causes 
it — or symptomatic; the latter is frequently present in many 
diseases of testicle and epididymis.. 

Spermatocele follows a weakening of the wall of some por- 
tion of the seminal tract, usually in the epididymis. The 
weakened portion of the wall distends with accumulated 

fluid, which is thin, grayish-white in color and contains 

163 



l64 AN OUTLINE OF GENITO-URINARY SURGERY 

spermatozoa, and forms a sac inside the cavity of the tunica 
vaginahs. 

Hematocele follows an injury to the scrotum and consists 
of a collection of blood, which may be clotted in the peri- 
testicular sac. 

All of these conditions cause enlargement of the scrotum. 
The tumor is elastic, fluctuant, and, unless acute, is not 
tender. The amount of fluid may vary in quantity from a 
thin layer overlying the testis to an accumulation of a pint or 
more. In hydrocele and hematocele the testis is surrounded 
by fluid and may be difficult to feel; in spermatocele the 
testis can usually be palpated outside the sac of fluid. The 
ability of the fluid to transmit light when placed before a 
strong light and viewed through a tube, pressed against the 
scrotum on the opposite side from the illumination, indicates 
hydrocele or spermatocele. Hematocele is, of course, opaque, 
and often feels firm, owing to the presence of clots. The 
differentiation between hydrocele or spermatocele and hernia 
must always be carried out. The former transmit light; 
hernia does not. When the patient coughs, hernia gives an 
impulse to the finger placed within the external inguinal ring. 
In hydrocele, one should be able to hold the spermatic cord 
between the fingers and rule out absolutely the presence of an 
impulse on coughing. There is a venous wave caused by 
coughing or forced expiration which may simulate a hernial 
impulse. 

Given a fluctuant, non-tender, or only slightly tender 
tumor of the scrotum, one rules out by the history traumatic 



DISEASES OF SCROTUM AND TESTICLE 165 

hydrocele and hematocele. It is a noteworthy fact that many 
cases of scrotal disease attribute their trouble to an injury, 
when really the accident which they imagine caused the ab- 
normality simply serv^ed to draw attention to the scrotum. 
Traumatic hydrocele and hematocele do not occur except as 
a result of injury of really considerable violence. 

Hernia, traimiatic hydrocele, and hematocele being ruled 
out, the diagnosis must be made between spermatocele, 
idiopathic hydrocele, or hydrocele accompanying some un- 
derlying disease of testis or epididymis. This is done by 
tapping the sac and emptying it of the fluid. The character 
of the fluid withdrawn will tell a good deal about its etiology. 
Grayish white fluid denotes spermatocele; turbid yellow 
fluid, symptomatic hydrocele. Clear yellow fluid may be 
either idiopathic or symptomatic hydrocele. 

For tapping a hydrocele of small amount one may use a 
lo-c.c. syringe equipped with a fairly large needle (Fig. 38). 
For emptying larger collections of fluid a trocar of small cali- 
ber is better. The scrotum should be washed thoroughly with 
soap and water. The spot to be tapped may be rubbed with 
alcohol. The instruments must be boiled. The operator 
stands on the patient's right; with his left hand he encircles 
the scrotum above the tumor, and by pressure from above 
downward renders the skin smooth and the tumor tense. 
The trocar, or needle, held in the right hand with the fore- 
finger upon the shaft i J inches from the point, is plunged with 
a quick motion into the tumor in its lower, anterior quadrant. 
The point must be carried forward to avoid stabbing the 



1 66 AN OUTLINE OF GENITO-URINARY SURGERY 

testis. The forefinger serves as a guard to prevent the in- 
strument from entering too far; when the point is felt to be 
free in the sac, the obturator is removed and the fluid al- 
lowed to escape into a basin placed upon the patient's thighs. 



1 


P^^m^ -^. ■ jfm,. '*■'? 


V 


s^' ^\^\ 


1 





Fig. 38. — Tapping a hydrocele. 

During this process pressure exerted by the left hand upon 
the tumor should be continued until every bit of fluid is 
withdrawn. Upon removing the needle the wound closes 
by the contraction of the dartos muscle. When the scrotum 



DISEASES OF SCROTUM AND TESTICLE 167 

is emptied of fluid its solid contents become easily palpable. 
They should be carefully outlined; the size and consistency 
of the testicle noted, and the size, hardness, and sensitive- 
ness of the epididymis. If disease is found, the cure of the 




Fig. 39. — Area to be infiltrated in operations upon the scrotum under 
local anesthesia. The line of infiltration extends entirely around the 
scrotum. 



hydrocele depends upon the relief of this; if the fluid be due 
to spermatocele or to idiopathic hydrocele, radical cure of 
the condition should be sought by operation. Spermatocele 
and hydrocele almost always refill after being tapped, and 



1 68 AN OUTLINE OF GENITO-URINARY SURGERY 

the removal or obliteration of the sac which secretes or con- 
tains the fluid must be carried out to effect a cure. The ob- 
literation of the sac by the introduction of irritating material 
—catgut (Whitney), carbohc acid (Keyes)— has seemed to 
us an unnecessarily blind procedure, when radical cure by 
operation can be done with so little risk under local anes- 
thesia. 




Fig. 40. — Hydrocele sac dissected free from scrotum and attached only 
by spermatic cord. 

To secure local anesthesia for operations upon the scrotal 
contents the following technic has been found very satisfac- 
tory: 60 to 80 c.c. of J per cent, novocain with adrenalin is 
used, injected with a 5- or lo-c.c. syringe equipped with a 
sharp needle i| or 2 inches in length. The proposed line of 
incision on the front of the scrotum is infiltrated. The infil- 
tration is carried upward to the level of the external inguinal 
ring. Where the spermatic cord crosses the pubic bone it is 



DISEASES OF SCROTUM AND TESTICLE 



169 



picked up and held firmly between the fingers. About 5 c.c. 
of the solution is injected into the cord. A hne of infiltra- 
tion is then carried all the way around the base of the scro- 
tum. After the injection the operator should wait ten min- 
utes before beginning the operation. A vertical incision is 




Fig. 41. — Resection of the hydrocele sac. 



made on the anterior surface of the scrotum. It is carried 
down to the tunica vaginalis, which is not opened. By blunt 
dissection the tunica with its contents is freed from the 
scrotum. The fluid may be allowed to escape, so that the 
tunical sac may be extruded ihrough the skin incision. The 



lyo AN OUTLINE OF GENITO-URINARY SURGERY 

tunica is then opened and its contents inspected. If there is 
a hydrocele, the tunica vaginaUs should be cut away on all 
sides I inch from its attachment to the testis. If the cut 




Fig. 42. — Parts of the Alexander bandage: 1. Upper, waist band. 2. 
Lower, scrotal bandage. 

edge bleeds it should be whipped with plain catgut. Sper- 
matocele is treated in practically the same way. The pouch 
which contains the spermatic ihiid must be cut away as well 



DISEASES OF SCROTUM AND TESTICLE 



171 



as the tunica vaginalis. The testis is then replaced in the 
scrotum, a rubber-tissue drain inserted, and the skin incision 
closed with silkworm-gut sutures. In operating upon the scro- 
tum under local anesthesia great care must be used to pick 
up every bleeding point. Smaller vessels, in fact, may be so 
contracted by the adrenalin that they do not bleed during the 
operation, but will ooze after the adrenalin has been absorbed. 




Fig. 43. — Right hand supports center of bandage in perineum. 

This is especially likely to happen when considerable raw 
surface is exposed, as occurs in the freeing of a large hydrocele 
sac. Careful hemostasis and a tight dressing are, therefore, 
very necessary. 

To secure pressure after operations upon the scrotum an 
Alexander bandage (so named after the late Doctor Samuel 
Alexander of New York) may be used (Figs. 42-47). It 



172 AN OUTLINE OF GENITOURINARY SURGERY 




Fig. 44. — Lower edge of bandage pinned tightly about scrotum. 




Fig. 45. — Upper edge of bandage pinned over scrotum. 

gives the necessary compression and elevation, and does not 
interfere with manipulations about the anus. The bandage 
consists of a strip of gauze 3 feet long by 20 inches wide, folded 



DISEASES OF SCROTUM AND TESTICLE 173 

twice so as to make a strip 3 feet long and 5 inches wide. To 
the middle of one edge is sewed the middle point of a piece of 
2-inch bandage 3 feet long. Another strip of gauze or flannel 
is needed to serve as a waist band. The point where the 
bandage is sewed to the gauze is placed on the perineum. 
The bandage ends pass one under each thigh and fasten to 




Fig. 46. — Bandage fastened to waist band. 

the waistband. The lower edges of the gauze strip are carried 
tightly around the base of the scrotum and at the root of the 
penis are pinned together. The same edges, higher up, are 
pinned to the waistband. The free edges of the gauze strip 
are then pinned tightly over the scrotum. A tuck is made 
at the bottom of the scrotum to make the bandage fit better. 
By drawing upward upon the free edges the whole scrotum 



174 AN OUTLINE OF GENITO-URINARY SURGERY 

is crowded against the pubes, thereby giving all the com- 
pression desired. 

Traumatic hydrocele and hematocele may be treated with 
rest in bed, elevation of the scrotum, and appHcation of ice. 
Continued pain due to distention of the sac may be met by 
tapping or by opening and draining the sac; in severe injuries 




Fig. 47. — Alexander bandage completed. Note how scrotum is pressed 
against pubes. 

the latter is probably the more conservative measure, as 
extreme pressure may damage the testicle, or the hemor- 
rhage may be due to a rupture of the tunica albuginea, which 
requires suture. 

DISEASES OF THE SPERMATIC CORD 
Hydrocele of the cord is a collection of fluid within an iso- 
lated bit of peritoneal sheath which was not completely ob- 



DISEASES OF THE SPERMATIC CORD 



175 



literated after the passage of the testicle. It appears as a 
smooth, elastic tumor situated in the spermatic cord, some- 
where between the testicle and the internal ring. It suggests 




Fig. 48. — Open operation for the radical cure of varicocele. The 
mass of veins included within the dotted lines is removed and the cut 
ends are tied together. 



hernia, and may be mistaken for it. If troublesome, the sac 
should be dissected out. 

Varicocele is the enlargement of the veins of the pampini- 
form plexus of the spermatic cord, occurring usually upon the 



176 AN OUTLINE OF GENITO-URINARY SURGERY 

left, and most frequently in young men. The condition 
may or may not cause symptoms; these consist of a dull ache 
in the region of the scrotum and a dragging sensation. 
Upon examination, a mass which feels like a ''bunch of angle- 
worms" is felt in the upper part of the scrotum. 

In very extreme cases it is possible that the nourishment 
of the testicle is interfered with and atrophy brought about, 
but in the vast majority of cases the condition is harmless and 
will clear up when the normal demands of sexual life are pro- 
vided for. Varicocele may be a manifestation of improper 
sexual hygiene. Ungratified sexual excitement, if continued 
for some time, will cause a very painful acute dilatation of the 
veins of the spermatic cord. Great relief is given by the 
wearing of a well-fitting suspensory; if the condition is ex- 
treme or continues to give symptoms, the excision of the 
dilated veins may be done, under local anesthesia if so desired. 
The possibility that a varicocele may be due to the pressure 
of a renal tumor upon the spermatic vein should be kept in 
mind. 

Torsion of the Spermatic Cord. — Occasionally the testicle 
rotates upon the pedicle by which it is suspended in the scrotal 
sac, or, in the case of undescended testicle, in the inguinal 
canal. The twist is supposed to occur because of an un- 
usually long mesorchium (the mesentery which holds the 
gland in place and through which the spermatic cord passes). 
Undescended testicle, because of the abnormal development 
of its attachments, seems peculiarly liable to this accident. 
As a result of the twist, which may consist of from one-half 



DISEASES OF THE SPERMATIC CORD 177 

a turn to four full turns, the circulation of the testicle is cut 
off and the gland quickly suffers irreparable damage. There 
is exudation of blood into the tissues; the testis and epididy- 
mis become swollen and bluish-black in color. This condi- 
tion may later resolve into a fibrous atrophy of the testicle, 
with loss of all its differentiated parenchymal cells, or may 
cause necrosis and abscess formation within the fibrous en- 
velope. 

The symptoms are sudden, severe pain in the scrotum and 
groin, with swelling of scrotal contents and reddening and 
edema of the skin. Clinically the condition resembles acute 
epididymitis so closely that the latter diagnosis is generally 
made. The absence of pus and shreds from the urine in such 
a case should make one very cautious of the diagnosis of 
epididymitis. Under rest and ice the pain and swelling gradu- 
ally subside, but the testicle remains hard and tender for a 
number of weeks, and may break down and require removal 
later. 

Operative untwisting of the torsion as early as one and one- 
half hours after the onset has not sufficed to save the testicle. 
Manipulation of the gland might conceivably untwist the tor- 
sion. Cases of recurrent torsion have been reported in which 
the patient himself was able to undo the twist. The extreme 
tenderness makes manipulation difficult, and if an anesthetic 
is given the scrotum had better be opened and a thorough 
inspection made. In case the untwisting of the cord at opera- 
tion is followed by the restoration of any circulation at all in 
the testicle, the gland should be left. It will atrophy, but 



1 78 AN OUTLINE OF GENITO-URINARY SURGERY 

even so, it will have a certain value in the eyes of the patient. 
If the case is seen late, or if the testicle is too obviously dam- 
aged, orchidectomy should be done. Expectant treatment 
may succeed in averting an operation, but the patient is liable 
to be troubled by a tender testicle for several months. 

DISEASES OF TESTICLE 

For the diagnosis of diseases of the scrotal contents one 
must be able to tell whether the disease is in the testis or in the 
epididymis. Certain diseases attack the former, others the 
latter. The term "epididymo-orchitis" or ''orchitis" has 
been used far too loosely. Fluid about the testis is the chief 
obstacle to an accurate diagnosis. In doubtful cases, there- 
fore, it must be withdrawn. The diseases of the testicle 
proper are: syphilis, trauma, torsion, new growth, tubercu- 
losis, abscess, and orchitis of mumps and of typhoid fever. 
Orchitis due to a diffuse infection of low virulence is occa- 
sionally seen. The diseases affecting chiefly the epidid- 
ymis are the infections due to the tubercle bacillus, the 
gonococcus, and the colon bacillus. Torsion and infection 
by the typhoid bacillus involve both. 

Trauma of the testicle, which will be either a bruise of the 
gland (treatment, rest and ice) or rupture (blood in tunical 
sac; treatment, expectant or operative, with suture of the 
tear), may be diagnosed by the history. 

Epididymo-orchitis of mumps comes on during the course 
of a parotitis. The testicle is swollen and very tender. It 
is ordinarily treated by rest, elevation, and ice. 



DISEASES OF TESTICLE 179 

Microscopic examination of tissue taken from a testicle in 
the acute stage of orchitis of mumps shows "a patchy degenera- 
tion of the tubules, with exudation into them of polymorpho- 
nuclear leukocytes and phagocytic endothelial leukocytes. 
The intertubular connective tissue is everywhere edematous, 
and between the tubules most affected it contains coarse, 
meshed fibrin, small areas of hemorrhage, and many poly- 
morphonuclear leukocytes and endothehal leukocytes. The 
picture suggests that the process is extending from the inter- 
tubular connective tissue into the tubules." No bacteria or 
other parasites were found. A late result in the majority of 
cases is atrophy of the testicle. 

Operation for this condition has been done; the timica al- 
buginea is incised to allow the drainage of the exudate which 
has been poured out into the testicular tissues. It may be 
that this procedure, if done early, will prevent to some extent 
the damage which will otherwise almost certainly result. 
The evidence upon this point is lacking. Following operation 
the pain is quickly alleviated, which suggests that the intra- 
capsular pressure has been reheved. 

Epididymo-orchitis of Mumps — Operation. — F. C, age twenty-two, 
cashier, single. Never sick except for measles. Denies venereal in- 
fection. July 1, 1912, the right parotid began to swell and be painful. 
A few days later the left side followed suit. July 9th the left testicle be- 
came sensitive and began to swell, and for two days got progressively 
worse. There was no burning on urination. 

My first examination, July 11th, showed a flushed, well-developed 
young man, with considerable swelling of both parotids. Thorax and 
abdomen normal. Xo urethral discharge. Right testicle normal. 
Scrotum contracted, not reddened. Left testicle was three times as large 
as its fellow, hard, smooth, only moderately tender. No hydrocele, skin 



l8o AN OUTLINE OF GENITO-URINARY SURGERY 

not adherent. Epididymis and vas not abnormal. Rectal examination 
showed a soft, small prostate, not tender. Vesicles not indurated. 
Temperature 104° F. Pulse 104. Respiration 26. He was sent to 
the Baptist Hospital, and flaxseed poultices applied. 

July 12th: Skin of scrotum red. Some hydrocele present. Testicle 
was larger and more tender. The epididymis had become palpable. 
Operation advised, but rejected. July 13th: Testicle felt a bit less swol- 
len. Hydrocele had increased. Epididymis was more clearly involved. 
The patient requested operation, which was done under ether, after soap 
and water and alcohol preparation. 

Operation. — A 2-inch vertical incision along anterior aspect of left 
scrotum. Tunica vaginalis opened, with escape of about 1 ounce of 
turbid yellow fluid from which a culture was made.^ The testicle was 
delivered through this incision. It was three times the size of a normal 
testicle, firm and elastic on palpation. The color was more bluish than is 
usual, and throughout the tunica albuginea were scattered many minute 
reddish specks, probably punctate hemorrhages. The epididymis was 
definitely enlarged, soft, without induration, and of a deep red color, 
which at the globus major became almost black. It was the picture of 
intense acute congestion. The cord was somewhat edematous, the vas 
normal. The tunica albuginea was slit with the knife in a dozen places, 
the incisions being not over \ inch long, parallel to the long axis of the 
testicle, and extending just through the tunica. There was considerable 
ooze from these, lasting a few moments; one spurter required a ligature. 
The testicular tissue showed no tendency to extrude. The tunica cover- 
ing the epididymis was also scored in about six places. 

The testicle was replaced in the scrotum, a rubber tissue drain left in, 
and the scrotal wound closed about the drain by a subcuticular silkworm- 
gut suture. Scrotum was tightly compressed in an Alexander bandage. 

July 14th: Temperature normal. No pain since operation. July 
15th: Same. Urine turbid, high colored, containing very slight trace 
of albumin. No sugar. Sediment: Some pus. 

July 16th: Drain removed. Testicle of normal size. Only slightly 
tender. 

July 17th 

July 19th 

July 20th 



Up and about. Urine still contains pus. 

Discharged from the hospital. 

Stitch removed. Testicles of same size. Urine spark- 



Ungly clear, no albumin. 

1 No growth, although a number of media were used. Monkeys 
were inoculated by injecting this fluid into the testicle, but orchitis 
did not result. 



DISEASES OF TESTICLE i8i 

Abscess of the testicle presents the signs of inflammation 
added to the testicular enlargement. It occurs almost al- 
ways as an accompaniment of colon infections of the lower 
urinary tract, and is most often found in old men with pros- 
tatic obstruction. A pyogenic infection of the testicle char- 
acterized by areas of focal necrosis, the so-called "Kocher's 
testicle," may be an early stage of abscess of the testicle. In 
such cases the testicle is enlarged, firm, and tender. Orchid- 
ectomy is the best procedure. 

Abscess of the testicle must be treated by incision and 
drainage or by castration. As a rule the entire contents of 
the testicular envelope become necrotic, so that castration 
does not deprive the individual of anything of value. 

Abscess of the Testicle. — C. J. J., age thirty-nine, single, entered the 
hospital October 3, 1914. He denied venereal disease and there was 
nothing of importance in his past history, except a street car accident five 
years pre\'ious]y, at which time his right leg was cut and bruised and he 
was obliged to walk on crutches for thirteen weeks. Eight months 
later he noticed that his left testicle was swollen. He went to the City 
Hospital, where the testicle was "lanced," with the escape of considerable 
pus. A few days later the testicle was removed. Since that time he had 
had no trouble and had felt well and strong until seven weeks ago, when 
he began to have pain in right testicle, but did not notice any change in 
size at that time. A few days later, however, it began to trouble him as 
he moved about at his work, and he noticed a slight increase in size, also a 
hard, slightly tender cord in the inguinal region extending into the scro- 
tum. At that time he felt "run down"; lost his appetite; was nauseated, 
and felt dizzy at times. This condition lasted only a few days, and since 
then he has felt perfectly well. The testicle, however, has continued to 
enlarge and has been slightly tender. 

Examination showed a healthy looking man. The left testicle was 
missing; the right was enlarged to equal a good-sized egg, smooth, and 
quite tender. Skin of scrotum not adherent, but reddened. Examina- 
tion of urine showed a few pus-cells, rare cast, and red cells. 



i82 AN OUTLINE OF GENITO-URINARY SURGERY 

October 5, 1914, operation, gas-oxygen anesthesia. A 3-inch vertical 
incision was made in anterior surface of scrotum and some hydrocele 
fluid evacuated. Testicle fairly adherent to tunica. On freeing the 
testicle it was found to be congested, elastic, and much enlarged, but of 
normal appearance. No nodules could be felt. Epididymis was flat, 
much congested, but not indurated. A small incision in the upper pole 
of the testicle set free about 6 drams of thick, yellow pus. When all the 
pus was evacuated nothing was left but a thin rim of testicular tissue. 
A rubber tube was passed through the testicle and out through a counter- 
opening in the lower pole of the testicle and scrotum. 

A culture of pus from the abscess showed colon-like bacilli. 

Convalescence was uninterrupted and the patient left the hospital 
October 14, 1914. 



Tuberculosis of the testis is always secondary to a similar 
process in the epididymis, but is by no means a frequent com- 
plication. In cases of long standing the epididymis may have 
sloughed away, leaving a tuberculous testicle. In such a 
case the chronicity and the presence of sinuses make the 
diagnosis of tuberculosis almost certain. 

Syphilis of the Testicle. — A non-tender enlargement of the 
testicle is due to one of two causes — syphilis or tumor. The 
differential diagnosis is not easy. A total lack of sensibility 
in the gland suggests syphilis, and, of course, a positive 
Wassermann tends to confirm this diagnosis. 

In every case in which the diagnosis between these two con- 
ditions is not perfectly clear, castration should be done. A 
gummatous testicle is not much of a loss, whereas the post- 
ponement of removal of a malignant testicle may be fatal. 

A syphihtic testicle may be so improved by antispecific 
treatment that it feels normal to palpation, although its 
functional recovery is improbable. Spermatozoa have been 



DISEASES OF TESTICLE 183 

recovered from healed leutic testes. If the gummata are 
broken down, castration will do away \\ith that lengthy 
process of disintegration through which the testicle must go. 

Neoplasm of the Testicle. — As has been shown by Ewing, 
practically all new growths of the testicle are teratomas — 
mixed tumors composed both of sarcomatous and carcino- 
matous elements. These tumors are quick to form metas- 
tases, which occur at first in the l}Tnphatic glands of the iliac 
and lumbar retroperitoneal region. Castration as high as pos- 
sible should be done immediately after the diagnosis is made. 
Postoperative treatment of the abdomen by a--ray with the 
hope of destroying metastatic growths should be carried out. 
Hinman points out that simple orchidectom}' has resulted in 
cure in only 1 5 to 20 per cent, of the cases operated upon at 
Johns Hopkins. He therefore ad\'ises the removal of all 
retroperitoneal lymph-glands on the affected side between 
the renal vessels and the inguinal canal. This should not be 
attempted, he says, if the glands in question are sufficiently 
involved to be palpated through the abdominal wall. The 
mortality of this procedure, in 46 cases reported. in the liter- 
ature, was II per cent. The operation is perfectly logical, 
but it seems too extensive for the rather doubtful benefits 
which it might yield. It should be kept in mind, however, 
for use in selected cases. 

Epididymitis. — Inflammation of the appendage of the tes- 
ticle is a distinct disease entity, and only Tarely is it accom- 
panied by corresponding disease of the testicle. Torsion 
and typhoid fever involve both; advanced tuberculosis 



l84 AN OUTLINE OF GENITO-URINARY SURGERY 

may involve both. In the vast majority of cases of dis- 
ease of the epididymis the lesion affects only that struc- 
ture itself, perhaps being prevented from entering the testicle 
by the stout envelope which envelops the gland. Under 
such circumstances the normal condition of the testicle is 
evident upon palpation, whereas the epididymis presents a 
hard, tender, crescentic tumor upon the posterior aspect of 
the testis. The globus major and globus minor are especially 
prominent. The vas is generally thickened. Differentia- 
tion of the scrotal organs may be obscured by fluid in the 
tunica; if the diagnosis is in doubt, this should be drawn off 
in order to make possible thorough palpation of the scrotal 
contents. 

The three infections commonly causing epididymitis are 
those due to the tubercle bacillus, the gonococcus, and the 
colon bacillus. Tuberculosis gives a hard, smooth, only 
slightly tender enlargement of the epididymis, limited some- 
times to one pole. The onset is insidious, or may be attrib- 
uted to some trivial injury. The urine may be normal or 
may show the signs of infection by the tubercle bacillus. If 
the latter, it will be hazy with pus, in a specimen of which, 
stained simply with methylene-blue, none of the ordinary 
bacteria appear. The prostate may be normal or may con- 
tain nodules; the seminal vesicle upon the infected side, how- 
ever, is very likely to be thickened and knotted. The vas 
in its scrotal course feels beaded, and as it approaches the 
globus minor it becomes thicker. The skin over the epididy- 
mis later becomes adherent, and the presence of sinuses is 



DISEASES OF TESTICLE 185 

almost pathognomonic of tuberculosis. A subsiding epididy- 
mitis due to the gonococcus or colon bacillus may resemble a 
tuberculous epididymitis. Chronic epididymitis, with mild 
exacerbations, is also puzzling. The history of urethritis or 
of an acute onset of the epididymitis weighs strongly against 
tuberculosis, although the possibility of the latter being super- 
imposed upon a gonococcus epididymitis must be considered. 

Epididymitis caused by the gonococcus and that due to the 
colon bacillus present the same symptoms. Both are acute 
infections. The onset is rapid and painful, the scrotum is at 
first tightly contracted, but quickly becomes edematous, red, 
and relaxed. After twenty-four hours the swelling of the 
epididymis becomes apparent, and reaches its maximum 
about the fourth day. It then becomes harder, but less 
painful, and from that point the enlargement gradually sub- 
sides. Sections of an acutely inflamed epididymis show the 
canals choked with detritus and pus-cells; the tissue between 
the tubules is edematous and contains collections of leuko- 
cytes. Macroscopically, the epididymis is purpUsh in color 
and perhaps coated wdth fibrin. The fibrous sheath is dis- 
tended, and through it tiny yellow collections of pus occa- 
sionally appear. Puncture of this sheath is followed by free 
oozing from the congested vessels, and perhaps by the extru- 
sion of a drop of pus. 

The differential diagnosis between epididymitis of colon 
origin and that caused by the gonococcus depends upon the 
history and upon the condition of the urine. Shreds in the 
urine and the history of a urethral infection point to the 



l86 AN OUTLINE OF GENITO-URINARY SURGERY 

gonococcus as the etiologic factor; the presence of residual 
urine, vesical tumor, calculus, or colon bacilluria suggests 
the colon bacillus. 

The treatment of tuberculous epididymitis will be consid- 
ered in the chapter on Genito-urinary Tuberculosis. 

The treatment of acute epididymitis consists of (i) sup- 
port; (2) heat. Rest in bed, with a flaxseed poultice and an 
efficient bandage, such as the Alexander bandage, gives good 
results. Elevation of the scrotum is essential. With such 
treatment the inflammation should quiet down in from five to 
ten days, but there is always the possibility that the epididy- 
mitis will flare up again when the patient gets out of bed. 
When ambulatory, the sufferer from epididymitis will get a 
good deal of rehef from wearing an elastic athletic supporter. 
The application of various drugs, such as magnesium sul- 
phate and ichthyol, has a very doubtful value. If one really 
wishes to clean up an acute gonococcus epididymitis without 
fear of recurrence, or if one has a case which has already 
suffered recurrences, the best treatment is the operation of 
epididymotomy. Under local or general anesthesia the 
testicle is exposed by a vertical incision on the anterior sur- 
face of the scrotum, is turned out of the scrotum, and the 
epididymis punctured in many places with a fine tenotome. 
Small abscesses are evacuated ; the testicle is replaced 
in the scrotum and the skin incision is closed with silk- 
worm-gut sutures. A rubber-tissue drain is left in the 
tunical sac. This operation is practically certain to cure 
the condition within one week, and can be done under local 



DISEASES OF TESTICLE 187 

anesthesia with very Httle pain. Expectant treatment may 
do as well, but cannot be depended upon to do so. 

Barney, J. D.: Abscess of the Testicle, Trans, of Amer. Assoc. Genito- 

urin. Surg., 1913, viii, 163-174. 
EwiNfc, J.: Teratoma- Testis and its Derivatives, Surg., Gynec, and 

Obst., 1911, xii, 230-259. 
Hagner, F. R.: a Further Report on the Operative Treatment -of Acute 

Gonorrheal Epididymitis, Ann. Surg., 1908, xlviii, 878-882. 
HixMAN, F. : The Operative Treatment of Tumors of the Testicle, with 

Report of 30 Cases Treated by Orchidectomy, Jour. Amer. Med. 

Assoc, 1914, kiii, 2009-2015. 
RiGBY and Howard: Torsion of the Testis, London Lancet, 1909, i, 

1415-1421. 
Smith, G. G. : Two Cases of Orchitis Due to Mumps Treated by Opera- 
tion, Boston Med. and Surg. Jour., 1912, clxvii, 323-325. 



CHAPTER XII 

DISEASES OF THE BLADDER 

A THOROUGH understanding of the diseases of the bladder 
is the key to diagnosis in urology. The bladder is the indi- 
cator for the entire tract. Like most generalities, this state- 
ment is only partially true, but it is true in a large enough 
proportion of genito-urinary diseases to be allowed to pass 
unchallenged. If the significance of the bladder symptoms 
is clearly appreciated, one can often go a considerable distance 
toward diagnosing the underlying lesion. The great mis- 
take is to treat all cases of pyuria as "cystitis," and in such 
cases to wash the bladder regularly for months when the 
trouble is really primary in the kidney or in the urethra. 

The bladder has but one way of voicing its dissatisfaction 
with existing conditions, and that is through some disturb- 
ance of micturition. Frequent micturition, however, may 
be due to any one of several different causes. A contracted 
bladder, the capacity of which is really limited by scar tissue, 
must be emptied more often than one the natural elasticity 
of which is unimpaired. Again, the bladder itself may be 
normal, but the posterior urethra may be hypersensitive. 
Stimuli to urination which would be disregarded by the nor- 
mal urethra are able to arouse the urinary reflex. There is 

i88 



DISEASES OF THE BLADDER 189 

the frequency of the ''overflow'' bladder, caused by the 
inability of the \'iscus to expel more than a few drams or 
ounces at each attempt. Or frequency may originate wholly 
in the nervous system, sometimes from functional derange- 
ment, sometimes from organic disease. Painful urination is 
a further development along the same line, and usually indi- 
cates a definite lesion of the bladder neck, such as ulceration 
of the mucosa. 

By far the commonest cause of bladder s\Tnptoms is in- 
fection. Disturbance of circulation, causing congestion of 
the posterior urethra or trigone, is a less frequent cause, unless 
we include cases of urinar}^ frequency in pregnant women. 
I believe that in many cases of supposedly aseptic congestion 
an underlying infection of urethral glands or prostate is the 
true cause. Of course, there are other causes of pain. Nerv^e 
lesions, such as pressure upon the roots of the sensor>" ner\-es 
of the bladder by spinal deformities or by metastases from 
cancer, may give vesical symptoms. Stone in the kidney or 
ureter may be the cause of irritabihty of the bladder even 
when infection is not present. This may be due to the 
existence of a renovesical reflex, although definite proof 
of such a reflex has not been presented. Vesical calculus, 
even when unaccompanied by infection, is, of course, 
likely to cause pain in the bladder by purely mechanical 
means. 

Cystitis. — ^Infection, however, is the great factor. In the 
vast majority of cases the organism is the colon bacillus; at 
times it is the staphylococcus or streptococcus, and not in- 



I go AN OUTLINE OF GENITO-URINARY SURGERY 

frequently the tubercle bacillus. Infection by other organ- 
isms is unusual, though not by any means rare. 

Practically never do we find an infection of the bladder 
without underlying cause. Acute infections may attend 
the sudden emptying by catheterization of overdistended 
bladders; this occurs most frequently when the traumatized 
bladder of the puerperium is allowed to distend and is then 
emptied at one catheterization. Acute infection of the 
trigonal portion of the bladder occurs during urethral infec- 
tions by the gonococcus. In the normal bladder such acute 
infections clear up quickly. A chronic cystitis means either 
(i) a constant supply of infectious material from some focus, 
such as kidney, prostate, or more rarely an appendix abscess 
or an inflamed fallopian tube adherent to the vesical wall; 
(2) the presence of residual urine, due to the inability of the 
bladder to empty itself. The cause of this may be in the 
reflex arc, as in tabes dorsalis or other cord lesion; a mechan- 
ical obstruction, as in cystocele, obstructing prostate or stric- 
ture; a diverticulitis, with retention of urine in the divertic- 
ulum. Or (3) cystitis may be due to a loss of the integrity 
of the bladder mucosa, as in ulceration due to syphilis, to 
stone, or to tumor. 

Differential Diagnosis.— How may these conditions be dif- 
ferentiated, and what can be done, short of cystoscopy, to 
work out the problem here presented? Unless the diagnosis 
is accurately made, treatment can be but symptomatic, and 
in too many cases will result in dissatisfaction and perhaps in 
wasted opportimities. 



DISEASES OF THE BLADDER 191 

The procedure to follow is simple enough. Given a case 
of acute cystitis from any cause, the first step is to abate 
the discomfort and, if possible, allay the virulence of the 
infection. 

Rest in bed, forced fluids, a bland diet — cereals, milk, and 
eggs — and free catharsis are the foundation for the treatment. 
Water, hot or cold, carbonated or plain, 100 to 150 ounces a 
day, is absolutely essential. As an additional measure, one 
may give an alkaU, preferably potassium citrate, combined 
with a bladder sedative: 

R. Potassium citrate 5v 

Tincture hyoscyamus 5v 

Water.. q. s. ad. 5iv 

A teaspoonful may be given in half a glass of water every 
three hours. 

Sandalwood oil (10 minims in capsules three or four times 
a day) is extremely soothing and of decided value in decreas- 
ing bacterial activity. 

The kidneys should always be palpated to determine the 
presence of tenderness, abnormal position, or enlargement. 
In the male a rectal examination should be made to deter- 
mine whether the prostate is concerned; in the female, vaginal 
examination is not so Ukely to yield information. 

In acute infections confined to the bladder the temperature 
should not be elevated more than a degree at most. Fever 
means infection of a parenchymatous organ, such as kidney 
or prostate. 



192 AN OUTLINE OF GENITO-URINARY SURGERY 

The urine must, of course, be examined. In the male 
catheterization is not necessary if the examination be done 
within an hour after the passage of the urine; in the female 
contamination by vaginal secretion really nullifies the find- 
ings in urine voided naturally. In women, a catheter speci- 
men is essential. 

The reaction of the urine is worth nothing. Tuberculous 
and colon infections are acid; if the urine is alkaline (before 
the administration of an alkali) an acute exacerbation of a 
chronic infection due to retention is suggested. The general 
characteristics of the urine should be noted. An ammoniacal 
odor means retention, either in bladder or in kidney pelvis. 
A smoky color means blood. Haziness without shreds 
suggests renal origin; shreds suggest a prostatic origin. A 
heavy deposit of pus suggests pyonephrosis. 

The diagnosis cannot be made by the finding of any one 
of the above characteristics, but the direction of future in- 
vestigations may be so indicated. The sediment should be 
examined for (i) blood, (2) pus. The detection of special 
cells from various portions of the tract is of some value. 
The cell which gives the most information is the caudate cell 
of the renal pelvis, the presence of which, of course, suggests 
a renal origin for the infection. 

The sediment should then be examined for bacteria. 
This procedure, described in Chapter II, will show whether 
the infectious agent is the colon bacillus or a coccus; the 
absence of ordinary bacteria in the presence of pus strongly 
suggests tuberculosis. If the latter is suspected, a specimen 



DISEASES OF THE BLADDER 193 

of urine obtained by catheter to avoid contamination by the 
smegma bacillus should be sent to someone experienced in 
the recognition of the organism, either in smears or by guinea- 
pig inoculation. The latter takes from five to six weeks, but 
the accuracy of the test makes the delay worth while in case 
the tubercle bacillus is not found in smears. 

Lavage of the bladder in acute cystitis need not be done, 
unless there are indications of the presence of a residual 
urine of several ounces or more. In the latter case lavage 
with boric acid (2 per cent.) will quickly reduce the inflam- 
mation. Daily instillations of argyrol (10 per cent.) may be 
used, but are not necessary. 

As the acuteness of the infection wears away, as it should 
in three or four days, hexamethylenamin may be substituted 
for the sandalwood oil, if the infection is due to the colon 
bacillus. From 30 to 45 grains a day should be given; as it 
yields formalin only in acid urine, the alkah should, of course, 
be discontinued. If the bladder is not sensitive the urine 
may be rendered more acid by the administration of sodium 
acid phosphate, 10 grains three or four times a day. In- 
crease of bladder irritabiHty means too mUch formalin in the 
urine; diarrhea may be caused by the sodium acid phosphate. 

In urinary tuberculosis hexamethylenamin acts only as an 
irritant, and has no curative effect. 

If the cystitis clears up entirely and the urine becomes free 
from pus, the administration of an antiseptic should be con- 
tinued for two weeks or a month. Two weeks after its dis- 
continuance a catheter specimen of urine should be cultured, 
13 



194 AN OUTLINE OF GENITO-URINARY SURGERY 

to make certain that there is not a residual bacilluria. Such 
a bacilluria will probably be of renal origin, and may cause 
pyelonephritis in case the patient, if a woman, becomes 
pregnant, or if a man, in case his resistance falls below 
par. 

If the signs of urinary infection persist, one may determine 
with considerable accuracy whether or not the focus is above 
the bladder by the following procedure: Wash the bladder 
thoroughly with boric acid solution until the fluid returns ab- 
solutely clear. The catheter is then left in place for a few 
minutes and the urine collected as it accumulates in the base 
of the bladder. If the infection is renal the urine should 
show about as much pus as did the bladder specimen; if 
the infection is not renal the urine so obtained should 
be very nearly normal — much more so than the bladder 
specimen. 

The information so obtained is not of great value, however, 
as it does not disclose the nature of the renal or the vesical 
lesion. The fact that there is infection in the kidney does 
not rule out a vesical lesion. On the contrary, the renal 
infection may be merely incidental to some pathologic condi- 
tion in the bladder. Infection in the bladder does not ascend 
the ureter through a normal ureteral orifice; the valvular for- 
mation prevents this. If the ureteral valve is dilated by 
back pressure, as in a chronically overdistended bladder, or 
the outflow of urine from the ureter is hindered by the pres- 
ence, of a diverticulum or the growth of a tumor, infection of 
the corresponding kidney soon follows. 



DISEASES OF THE BLADDER 195 

When cystitis is secondary to renal infection the cure of 
the latter will nearly always result in recovery of the former. 
If a low-grade chronic cystitis persists, it may be cleaned up 
by a few irrigations with silver nitrate solution (i : 5000). 
Tuberculous cystitis is an exception to the above rule, al- 
though even it shows a general tendency to follow the same 
principle. 

Encrusted Bladder. — There is one type of cystitis sometimes 
due to renal infection which requires special discussion. It 
is the form in which lime salts are deposited by an alkaline 
urine upon the bladder w^all. So-called "encrusted bladder" 
occurs oftenest, perhaps, in the presence of a residual urine. 
It may occur in bladders w^hich empty completely, and be 
caused by a coccus infection originating in the kidney. 

The treatment of such cases consists in keeping the urine 
acid, and instilling into the bladder every day or two 2 
ounces of a \dgorous culture of lactic acid bacilli, or the 
Bacillus acidophilus (Caulk). A very obstinate case which 
we treated at the Massachusetts General Hospital showed no 
real improvement until, probably as the result of ureteral 
catheterization, a colon bacillus infection was engrafted on 
to the coccus infection of the renal pelvis. The reaction of 
the urine then became acid and the bladder cleared up 
rapidly. 



Case of Encrusted Bladder.— C. L. E. No. 209,515. M. G. H., 
colored, age twenty-nine, married, came to Out-patient Department com- 
plaining of dysuria and passing of gravel with urine. Duration of this 
six years. Previous historj' unimportant. During past few years she 



196 AN OUTLINE OF GENITO-URINARY SURGERY 

has had attacks of "gastritis," manifested by epigastric pain, nausea, and 
vomiting. General examination negative. The urine was strongly alka- 
line and ammoniacal and contained considerable pus and red blood-cells. 
At cystoscopy the bladder held only 4 ounces. Over the left lateral 
wall were seen masses of white encrustation. Ureters could not be identi- 
fied. She was given bladder lavage and several instillations of Bacillus 
bulgaricus. Twelve days later the bladder held 7 ounces, but otherwise 
showed little improvement. Ureters were identified as round holes, not 
retracted. Both were catheterized. The right side yielded normal urine; 
that from the left contained pus and streptococci. No tubercle bacilli 
found. a;-Rays negative for stone. Wassermann negative. Treat- 
ment in the Out-patient Department was not followed by much improve- 
ment^ so one month after her first visit she was sent into the House. 
There she was kept in bed, given daily bladder irrigations, and instilla- 
tions of either Bacillus bulgaricus or Bacillus acidophilus twice a day. 
Cystoscopy after ten days of this showed that encrustations had entirely 
disappeared. Ureteral orifices appeared normal. Both catheterized, 
with good flow from both kidneys. Right side showed pus and blood, 
100 leukocytes per field; colon bacilli; phthalein output after intravenous 
injection — appearance time three minutes; 7.5 per cent, excreted in fol- 
lowing fifteen minutes. Left side showed pus, 50 leukocytes per field, 
colon bacilli, and streptococci. Appearance of phthalein, three and one- 
half minutes, L25 per cent, in fifteen minutes. For eight days after 
cystoscopy the patient ran a temperature of 101 ° F. This fell to normal, 
and eleven days after cystoscopy she was discharged from the house, hav- 
ing recovered entirely from her dysuria and the passage pi gravel. The 
urine remained acid. 

Chronic cystitis is always the result of some definite patho- 
logic process. It must be borne in mind that the symptoms 
of frequency and urgency do not warrant the diagnosis of 
cystitis. Especially in women, these symptoms frequently 
exist in connection with a chronic urethritis. Cystitis means 
inflammation of the bladder, and pus must be found in a 
catheter specimen of urine before the diagnosis is justified. 
The situation in regard to cystitis may be diagrammatically 
presented thus: Chronic cystitis = infection caused from 



DISEASES OF THE BLADDER I97 

I. Renal and ureteral infections, due to 

A. Calculus. 

B. Stricture of ureter.* 

C. Renal retention. 

D. Renal tumor. 

E. Chronic pyelitis or pyelonephritis. 
II. Residual urine in bladder, due to 

A. Nerve lesions. 

B. Prostatic obstruction. 

C. Diverticulum of bladder. 

D. Cystocele. 

E. Stricture of urethra, 

F. Tumor or stone acting as ball-valve. 

III. Adjacent foci which communicate with bladder: 

A. Entero vesical fistula. 

B. Pelvic abscess (appendix or tubes). 

C. Prostate or vesicles. 

IV. Ulcerations of vesical mucosa, caused by 

A. Syphilis. 

B. New growth. 

C. Calculus. 

D. Foreign body. 

The differential diagnosis between these various causes of 
chronic cystitis ultimately depends upon the cystoscope. 
Without it, even if a possible cause is found, as, for example, 
a pelvic abscess, one cannot be sure that the cystitis is not 
due to a coincident but entirely independent cause, such as 
a neoplasm. A true diagnosis is difficult enough to make, 



198 AN OUTLINE OF GENITO-URTNARY SURGERY 

at times, with all the facilities which we command. No case 
of chronic cystitis should be permitted to continue, after a 
therapeutic attack of reasonable length, without a cystoscopic 
examination. 

Once the diagnosis is made, the treatment of the cystitis 
is the treatment of its cause. Frequently this cause has to 
do with other organs: the treatment will be found in the 
appropriate sections of this book. Pathologic conditions 
concerning chiefly the bladder and not described elsewhere 
are disturbances due to nerve lesions, syphilis, bilharzia in- 
fection, neoplasm, and stone. 

A study of 87 cases of "cystitis" in women thoroughly 
investigated by modern methods of diagnosis showed that the 
bladder infection was associated with: 

Renal infections, not tuberculous, in 61 per cent. 

Renal tuberculosis in 19 per cent. 

Incomplete emptying of bladder in 7 per cent. 

Systemic and pelvic infections in 7 per cent. 

Other causes in 6 per cent. 
Not one case of chronic cystitis was found in which the 
process was not dependent upon some underlying cause (G. 
G. Smith). 

Residuum due to nerve lesions is most frequently found in 
the tabetic. The reflex arc is broken by the involvement of 
the roots of those sensory nerves which bring from the bladder 
neck the sensation of a desire to urinate. Instead of regularly 
emptying the bladder, the tabetic voids at irregular intervals, 
and may be totally unconscious of the fact that when he 



DISEASES OF THE BLADDER 199 

finishes urinating his bladder still contains 3 or 4 pints of 
urine. The muscle of the bladder wall strives valiantly to 
express the contents; it is opposed by the sphincter, which 
awaits in vain the signal to relax. The bladder wall becomes 
hypertrophied and the muscles develop in bundles; with the 
cystoscope this is shown by the trabeculation of the vesical 
wall. These bladders seem to be immune to infection to a 
remarkable degree. Sooner or later, however, it intervenes, 
and, as has been show^n by Barney, death is caused in a 
majority of tabetics by damage done to the kidneys through 
back pressure and infection. 

Treatment. — To avoid this termination, the aim of treat- 
ment must be the complete emptying of the bladder. The 
residuum must be emptied by catheter. Instrumentation is 
easy, as it is unusual to have troublesome enlargement of the 
prostate as a complication of tabes dorsahs. The combina- 
tion does occur, and for that reason every case of residual 
urme should be examined with regard to the four chief reflex 
tests for nerve disturbance, i. e., pupillary reaction, knee- 
jerks, ankle-jerks, Romberg. 

The frequency of catheterization should depend upon the 
amount of residuum. From 2 to 4 ounces require the catheter 
once a day; 4 to 8 ounces, twice daily; more than that requires 
regular catheterization three or four times in the twenty-four 
hours. 

Hexamethylenamin in efficient doses should be given, and 
the urine kept acid by acid sodium phosphate. If in spite of 
this the urine remains alkaline, the instillation into the 



200 AN OUTLINE OF GENITO-URINARY SURGERY 

bladder every day or two of an ounce of lactic acid bacilli in 
sterile water may be tried. The treatment of locomotor 
ataxia itself is not within the scope of this book. It is worth 
while, however, to mention the value of re-education of mus- 
cles as applied to the bladder. Filling the patient's bladder 
with fluid, and, as he voids this, making him stop and start 
the stream at the word of command, may enable the patient 
to get control over his external sphincter, so that it makes an 
acceptable substitute for the internal sphincter. 

Other and less well-recognized nerve lesions are those due 
to the effects of diphtheria toxin, which may be manifested 
years after the attack of diphtheria, those due to pressure 
upon the cord or to involvement of the cauda equinae, as in 
Pott's disease, or in spina bifida and spina bifida occulta, and 
those due to syringomyelia, transverse myelitis, and multiple 
sclerosis. 

Bladder Disturbance Due to Syringomyelia. — A patient with syringo- 
myelia exhibiting marked bladder symptoms entered the Massachusetts 
General Hospital on the geni to-urinary service in October, 1916. The 
relation between the vesical disturbance and the nerve lesion was not 
perfectly clear, yet we were unable to account for the former in any other 
way. The patient was a woman of thirty, a domestic who had had three 
illegitimate children. Two of them were born dead; the last one, which 
lived, was born five years before. The patient complained of painful, 
burning micturition of eight weeks' duration. Urination was followed by 
dribbling, tenesmus, and a desire to urinate again. The urine contained 
pus and colon bacilli. Cystoscopy was done under spinal anesthesia. 
Considerable trabeculation of the bladder wall with a distention of 6 
ounces was noted. Both ureters were catheterized; a small amount of 
pus and a growth of colon bacilli were obtained from each. Roentgen- 
oscopy and the Wassermann test were negative. The peculiar thing was 
that during her twelve days in the hospital the patient continued to have 
constant severe spasms of the bladder in spite of every kind of local 



DISEASES OF THE BLADDER 201 

treatment. Also, she had, on several separate observations, a residuum 
of 6 ounces. 

She was seen in consultation by Drs. Paul and Taylor, who made the 
diagnosis of syringomyelia because of atrophy of the small muscles of the 
hands and various sensory disturbances. 

Bladder Disturbance Due to Multiple Sclerosis. — M. C, a nurse, aged 
twenty-eight, was seen about one year ago. Four years before, while in 
training, she became "run down" and ver}'- nervous. Previously she had 
always been well, except for measles. Accompanying her breakdown 
were bladder symptoms — great frequency and inability to control her 
urine. Association with insane persons led her to fear that she might 
have some nervous disease, so she went to the Massachusetts General 
Hospital and had an examination of the spinal fluid. This was normal. 
She returned to work and has remained at it, in spite of a sense of weak- 
ness in the legs, and what she characterizes as a "weakness of the blad- 
der." At times she wets the bed at night. 

She was a rather pale, tired-looking girl. The pupils reacted nor- 
mally. There was no Romberg; the knee-jerks were normal; general ex- 
amination was negative; the kidnej's were not palpable; the pehdc organs 
were normal. The urine by catheter was hazy, revealing no sugar or al- 
bumin. A centrifuged sediment showed some pus-cells, a few red blood- 
cells, and vast quantities of staphylococci. No tubercle bacilli were 
found. Roentgenoscopy was negative for stone. 

The bladder contained 4 ounces of residual urine; with distention of 8 
ounces the bladdei wall showed a fine trabeculation; the mucous mem- 
brane was clean. The ureteral orifices were normal. Both ureters were 
catheterized, with a flow of normal urine. 

Not being awake to the diagnosis, and finding the urethra abnormaUy 
red and granular, I treated her with urethral applications, sandalwood oil 
and bladder lavage. The residual urine remained about 4 ounces through- 
out July, August, and September. In November I noted that her chief 
trouble was a sensation of weakness in the front of the legs. The bladder 
symptoms improved a very little, the greatest improvement following 
rest from work, bromids, and belladonna. 

The patient was very emotional, laughing one moment, crying the 
next. On December 22d the residuum was only 1| ounces. In Decem- 
ber I sent her to Dr. George Clymer for neurologic examination. He re- 
ported that he found a positive Babinski, negative abdominal and epi- 
gastric reflexes, and positive ankle-clonus — in short, that she unquestion- 
ably had multiple sclerosis. 

He started treatment \^^th solution of potassium arsenite (Fowler's 
solution) and the application of electricity over the bladder. Whether or 



202 AN OUTLINE OF GENITO-URINARY SURGERY 



not as a result of this treatment, the patient showed remarkable improve- 
ment. The residuum cleared up, the urine became normal, and for two 
months she wet the bed only during menstruation. She has had a 
slight remission, but, generally speaking, is much better, and has started 
to work again. 

Although these are unusual causes of urinary retention, 

they should be borne in mind whenever one is searching for 




Fig. 49. — Bilharzia ova in urine. Lower power of urinary sediment, 
showing blood, pus, crystals, and ova. In upper right-hand corner is 
miracidium that has just hatched out, leaving the empty shell behind it 
(to left); X200 (Lane). 

the cause of residual urine. Multiple sclerosis occurs in 
young women especially, and the detection of this condition 
may explain an otherwise inexplicable residual urine. 
Another factor in disturbance of the bladder innervation 



DISEASES OF THE BLADDER 203 

has been pointed out by Chute. Frank spina bifida is a well- 
recognized cause of bladder paralysis, but Chute has reported 
several cases of spina bifida occulta, in which the a;-ray re- 
vealed a defect in the wall of the vertebral canal, and in 
which there was partial or complete retention of urine. 

Syphilis of the bladder is of rather infrequent occurrence. 
At least the recognized cases are few. There is nothing 




Fig. 50. — High power of o\-um shovring structure; X 375 (Lane). 

especially typical about the lesion. It consists of an ulcera- 
tion of the bladder wall which does not respond to lavage, but 
which quickly disappears under antispecific treatment. 

Bilharzia infection is worth mentioning because it is oc- 
casionally met with in our hospital clinics. E. L. Young 
had 2 cases in one year. The symptoms are similar to 
those of bladder tumor, and the appearance of the lesion is 
not unlike that of an infiltrating, soUd growth. The finding 



204 AN OUTLINE OF GENITO-URINARY SURGERY 



of the ova in the urine is, of course, the essential factor in 
diagnosis, 




Fig. 51. — Represents miracidium swimming about, showing the different 
forms assumed; X 375 (Lane). 




^> 



^ 



Fig. 52. — Empty ovum after escape of miracidium, X 375 (Lane). 

Tumor. — Bladder tumors are either benign or malignant. 
The common benign tumor is the papilloma; the rarer benign 



DISEASES OF THE BLADDER 20$ 

tumors are those composed of fibrous, smooth muscle or 
mucilaginous tissue. Malignant bladder tumors are either 
papillary carcinoma (papillomata which have undergone 
malignant degeneration), squamous-celled carcinoma, or 
sarcoma. Carcinomata of the epithelial type are meaty, 
solid growths, sessile in form, or are ulcerative in char- 
acter. For practical purposes all papillomata are malignant, 
inasmuch as they all tend to recur. Even when the original 




Fig. 53. — Drawing of papilloma of bladder as seen through cystoscope. 
The tumor springs from the posterior lip of the ureteric orifice. 

tumor is declared benign after the most exact examination, 
the recurrence may be definitely carcinomatous. Bladder 
tumors may exist for years without giving symptoms. If 
situated near the internal orifice, the tumor may act as a 
ball-valve and cause partial retention or "stammering" of 
the stream. Otherwise the first symptom is frequently hema- 
turia — usually terminal. If the tumor becomes ulcerated 
and infected, the symptoms of cystitis appear. 



206 AN OUTLINE OF GENITO-URINARY SURGERY 

The benign tumors are injurious chiefly because of the 
infection which they cause, and sometimes because of the 
constant leakage of blood and consequent anemia. The 
hemorrhage may be severe enough to fill the bladder with 
clots. 

Malignant tumors are dangerous- for the same reasons, and 
also because of their steady growth. Ureteral orifices may 
be obstructed, causing renal retention and infection. Metas- 
tasis from bladder tumors is relatively late, and early opera- 
tion offers excellent chances for cure, or at least for a consid- 
erable prolongation of life. 

The presence of bladder tumor should be suspected in 
every case of hematuria. In order to detect bladder tumor 
early, cystoscopy should be done in every case of hematuria, 
even if the bleeding has stopped, and in every case of unex- 
plained pyuria. The treatment should be based upon the 
cystoscopic picture. It is poor surgery to open the bladder 
for tumor unless the nature and position of the growth are 
known. 

Treatment of the benign types consists simply of removal of 
the tumor. In the case of solid, meaty tumors, such as fibro- 
mata, this must be done by open operation. Benign papil- 
lomata may be removed by the intravesical route, that is, by 
thermocoagulation with the high-frequency current. 

The spark is applied to the tumor by means of an insulated 
wire passed through one of the catheter channels of the cysto- 
scope. The unipolar method is generally used in this country. 
As the tip of the wire lies in contact with the tumor, the cur- 



DISEASES OF THE BLADDER 207 

rent is turned on, and the papilloma rapidly disintegrates at 
the place where the wire touches it. From one to fifteen or 
twenty treatments may be required, but if the tumor does 
not respond fairly soon to this method, it should be judged 
mahgnant and removed by open operation. 

The question of. the practicabihty of this method of treat- 
ment must be left to the cystoscopist. 

Papilloma of Bladder Removed by Fulguration. — F. E. H., a traveling 
salesman of forty-six. came to me April 12, 1915, because of hematuria. 
Thirty years before he had passed a stone; twenty-five years before he 
had had ''orchitis." Past history otherwise negative. 

In October of the preceding year he first noticed a little blood at the 
end of urination. This lasted for some time, with no discomfort what- 
ever. The blood then disappeared until one week ago. Lately he has 
noticed that urination may be suddenl}- interrupted. Frequency every 
two hours by day, once at night. General examination negative. Urine 
tinged with blood. 

C\'stoscopy showed a typical papilloma about as large as a cherry 
springing from the outer side of the right ureter and hiding the orifice. 
The bladder showed slight trabeculation, but was otherwise normal. 
The tumor was fulgurated nine times between May 1st and July 2d. On 
the latter date a small stub remained, which was thoroughly fulgurated. 
He was cystoscoped at intervals of six months. In August, 1916, one 
tiny bud was seen, just behind the right ureter. This bud was fulgurated 
twice. He was last cystoscoped December 28, 1917, at which time there 
was no sign whatever of any tumor. 

Papilloma of Bladder Removed by Open Operation. — S. D. P., a 
tailor of fifty-five, came to me in March, 1915, with a history almost 
identical with that of the preceding case. Seven months previously he 
had noticed a little blood at the end of urination. He was given formin 
tablets, and the bleeding stopped. Three weeks ago it began again. He 
urinates every two hours by day, t\\-ice at night. No loss of weight. 
General examination negative. Urine hazy, with specks of blood floating 
in it. Cystoscopy showed a papillary tumor about H inches in length 
arising from the left lateral wall of the bladder, about 1 inch outside the 
left ureter. Owing to the mental attitude of the patient operation rather 
than fulguration was advised. On jMarch 10, 1915, suprapubic cys- 



2o8 AN OUTLINE OF GENITO-URINARY SURGERY 

totomy, extraperitoneal, was done. A tumor with small pedicle was re- 
moved with the underlying mucosa. The bladder was closed tight and a 
rubber tissue drain placed down to the bladder wall. Primary healing 




Fig. 54. — Implantation of ureter. Peritoneum stripped off bladder. 
Ureter held up by tape, preparatory to being cut and reimplanted. 



took place. The tumor, on section, turned out to be a simple papilloma. 
There was no evidence of infiltration of the base. 

The patient was cystoscoped every six months up to June, 1917. As 
he then showed no sign of recurrence, he was told to report in one year. 



DISEASES OF THE BLADDER 



209 



Malignant tumors must be removed; not only the tumor, 
but that portion of the bladder wall upon which they are 
borne, must be excised. Partial cystectomy is possible in a 





Fig. 55. — Implantation of ureter. Cut end of ureter being drawn 
through bladder wall. Ureter fastened at point where it enters bladder 
wall by two sutures of chromic catgut. 



great many of these tumors, even if a ureteral orifice is in- 
volved. In that case the ureter is transplanted into another 
part of the bladder. If the growth is too widely spread about 
the bladder to permit of this, radical treatment means drain- 
14 



2IO AN OUTLINE OF GENITO-URINARY SURGERY 

age of the kidneys either by ureterostomy, by implantation 
of ureters into the bowel, or by nephrostomy, and total re- 
moval of the bladder. The operation of cystectomy, followed 
by the establishment of urinary fistulse on to the surface of 
the body, is not to be recommended lightly. Yet in the 
case of certain bladder growths, which, although wide-spread 




Fig. 56. 



Tmplantation of ureter completed, 
the bladder. 



Ureter projects ^ inch into 



locally, have not produced detectable metastases, the opera- 
tion offers far more to the patient than does the palliative 
cystostomy or simple vesical curetage and cauterization, 
which is generally done. 

In considering the pros and cons of cystectomy one should 
remember that unless a man has the leisure and the intelli- 
gence to care for his nephrostomy tubes or his ureterostomy 



DISEASES OF THE BLADDER 



211 



apparatus he had better not have either of those operations 
done even to save his life. 




Fig. 57. — Situation of the fistulae in bilateral nephrostomy. The tubes 
which drain the renal pelves have been removed. 

If none of the above measures can be employed, simply 
opening and draining the bladder, with cauterization of the 



212 AN OUTLINE OF GENITO-URINARY SURGERY 

tumor, will make his remaining days easier and perhaps a 
little longer. 

Within the last year or two rather encouraging reports 
have come from Hugh Young and from Barringer in regard 
to the value of radium in the treatment of bladder carcinoma. 
As yet this treatment is not on an estabhshed basis. With 
some tumors, even inoperable ones, the use of radium gives 
wonderful results. Other tumors do not improve perma- 
nently at all. Unquestionably this treatment has great possi- 
bilities; at present the consensus of opinion, even among its 
advocates, seems to be that if a tumor is operable it should 
be removed. Radium should be reserved for those tumors 
which cannot be removed with any hope of cure, or for recur- 
rences after operation. 

The choice of treatment demands careful consideration 
and a thorough knowledge of the patient — of his renal 
condition, his general health, his economic condition, and, 
indeed, of his mental attitude toward life. A radical pro- 
cedure such as cystectomy should not be attempted 
without the understanding and co-operation of the 
patient. 

Vesical Calculus. — Stone in the bladder may occur at any 
age and in either sex. The condition is most frequently found 
in bladders in which a residual urine exists. The stagnation of 
the urine and the alkalinity which results from bacterial growth 
are both factors in deposition of urinary salts. A few cases of 
aseptic stone are seen in which the symptoms are entirely due 
to the mechanical effect of the foreign body. Pain when be- 



DISEASES OF THE BLADDER 213 

ing jolted or jarred is fairly pathognomonic, especially if ac- 
companied by fresh blood in the urine. 

In prostatics, pain in the bladder and vesical irritability 
which do not yield readily to hygiene and balsamics are 
very suggestive of stone. The possibility of vesical calculus 
shoul(^ also be borne in mind in cases of urinary incontinence 
in childhood. The fact that the urine is uninfected does not 
necessarily exclude stone. 

Ordinarily, unless the urethra is obstructed, a stone can be 
detected by filling the bladder with fluid (boric acid) , passing 
a small sound (No. 20 French), and gently moving the beak 
about the bladder. It should be remembered that encrusted 
tumors may give the same grating sensation. The diagnosis 
is best made by the cystoscope, although the ri'-ray will tell a 
good deal about the size and density of the calculus. The 
treatment consists in crushing and removing the stone by the 
operation of litholapaxy, which is far superior to cystotomy, 
in that the patient is confined to bed for a few days only, and 
is not subjected to the risks of wound sepsis and a urinary 
fistula. There are some cases in which the open operation is 
preferable, in fact, necessary. Extreme youth is a contra- 
indication to litholapaxy. Calculi complicating diverticu- 
lum or obstructing prostate may be very difficult to crush, 
and may have to be removed by cystotomy. 

Rupture of the bladder occurs most frequently in acci- 
dents in which the victim is crushed between two heavy bodies 
or is run over by a very heavy vehicle. It may happen to 
women during childbirth if the bladder is not emptied before- 



214 AN OUTLINE OF GENITO-URINARY SURGERY 

hand. The rupture usually breaks into the loose perivesical 
tissue; less often, into the peritoneum itself. The symptoms 
are severe shock, the passage of bloody urine by urethra, 
or inability to void. If the rupture is intraperitoneal, the 
abdomen becomes distended and free fluid may be demon- 
strated. If it is extraperitoneal, the escaped urine infiltrates 
the areolar tissue of the pelvis and later forms an abscess. 
If, following an injury, the patient passes only a little blood 
and no urine, the diagnosis of rupture of the bladder is prob- 
able. Rupture of the urethra must be ruled out by the 
passage of a catheter. Through this the surgeon injects 
4 ounces of boric acid solution into the bladder. The re- 
turn flow should be accurately measured. If it is less than 
the amount injected, exploration should be done. If aU the 
fluid returns, but is bloody, one may reason that the rupture 
is incomplete, and is certainly not intraperitoneal. It is 
justifiable to fasten a large soft-rubber catheter in the urethra 
and keep the patient under close observation. Catheteriza- 
tion should not be done unless one is prepared to operate 
immediately in case a definite rupture exists, for with cath- 
eterization infection sets in, and converts a comparatively 
harmless extravasation into a culture-medium of the best 
sort. If at operation rupture is found, it should be sutured, if 
accessible; the bladder should be drained with a large rubber 
tube, and the extraperitoneal space also drained. If in 
doubt whether or not to operate, one should elect the more 
radical course, as rapid exploration is less harmful than an 
undrained extravasation. 



DISEASES OF THE BLADDER 215 

Barney, J. D.: The Care and Management of the Tabetic Bladder, 
Boston Med. and Surg. Jour., 1910 and 1911, clxiii, 933-937; clxiii, 
965-9^0; clxiv, 13-17. 

Caulk, J. R.: Encrusted Cystitis, Trans. Amer. Assoc. Genito-urin. 
Surg., 1914, ix. 

Fowler, H. A.: Syphilis of the Bladder, Jour. Amer. Med. Assoc, 1917, 
Ixix, 1399-1402. 

Geraghty, J. T. : The Results of Treatment of Bladder Tumors, Jour. 
Amer. Med. Assoc, 1917, Ixix, 1336-1342. 

Lane, C. G.: Bilharziasis. Report of a Case with Appendicitis. Liter- 
ature since 1904, Boston Med. and Surg. Jour., 1910, clxiii, 937-940. 

Smith, G. G.: Chronic Cystitis in Women Not a Disease, Jour. Amer. 
Med. Assoc, 1913, Ixi, 2038-2041. Bladder Disturbances Due to 
Nerve Lesions, Jour. Amer. Med. Assoc, 1917, Ixix, 1323-1327. 



CHAPTER XIII 

DISEASES OF KIDNEYS AND URETERS 

Diseases of the upper urinary tract may be discovered 
through routine examination of urine, but, as a rule, the 
patient's attention is attracted by some symptom caused by 
his condition. 

The important signs and symptoms of renal or ureteral 
disease, more or less in the order of their importance, are: 

(1) Urinary abnormalities. 

(2) Pain. 

(v3) Disturbances of urination. 

(4) Fever. 

(5) Abdominal tumor. 

(6) Signs of uremia. 

1. Urinary Abnormalities. — ^The abnormality most start- 
ling to the patient is hematuria. Renal hematuria may give 
the urine a bright color, but, as a rule, is characterized by a 
"smoky" hue. Hematuria may be the only sign of renal 
disease. The causes are numerous. Early chronic nephritis 
may cause quite profuse bleeding. Varix of a renal papilla, 
early hypernephroma, or renal stone may be the cause; there 
may be no pain and no tumor — simply a silent bleeding. 
Hematuria accompanied by pain is significant of stone; ac- 
companied by tumor, it suggests hypernephroma. If no 

2l6 



DISEASES OF KIDNEYS AND URETERS 217 

localizing signs appear, such as pain or tumor, one cannot tell 
whether the bleeding is from kidney or from bladder, except 
by the cystoscopy Once again let the rule be emphasized: 
Every case of hematuria, with the sole exception of those in 
which the hemorrhage is clearly from the prostate, should be 
cystoscoped at once. 

Hematuria of Chronic Nephritis. — L. L. P., age thirty-eight, veterin- 
ary surgeon, seen February 28, 1914. Pneumonia when five years of age; 
tonsillitis sixteen years ago. Has "grip" once every year. Three years 
ago had an attack of weakness and dark-colored urine, lasting for one 
week. Last winter had a second similar attack. This winter one slight 
and one severe attack. Has had headaches for past year, which he thinks 
are due to constipation. He has never had edema and has no frequency 
of urination. 

Physical examination showed an apparently healthy man. General 
physical examination negative. Heart not enlarged; sounds clear. 
Systolic blood-pressure 180. Neither kidney palpable or tender. Phthal- 
ein test, intramuscular: color appeared in seven minutes; 45 per cent, 
was excreted in the following hour. Urine hazy; acid; sp. gr. 1014; 
albumin large trace; sugar 0. Sediment: much blood; some pus; a few 
casts; no bacteria seen. Culture negative. Guinea-pig inoculation 
negative. 

Cystoscopy March 18, 1914, shows normal bladder. Both ureters 
catheterized. Urine from right shows blood-cells; a few finely granular 
casts; no pus or bacteria. The left shows much blood; no pus or casts; 
motile bacteria. Culture: right, negative; left, sta'phylococcus. 

During the next month the urine gradually cleared up. The specific 
gravity remained around 1005 and there were constantly a few casts in 
the sediment. ^May 15, 1914, says he has felt very well, and that urine 
has been clear. Urine, however, was found to be hazy; sp. gr. 1016; 
albumin very slight trace. Sediment: some red blood-cells. Blood- 
pressure, systolic, 165. Nothing further was heard from him until 
January 24, 1916, when he had another attack of hematuria. He had 
had none for the previous two years. The urine was very bloody, with 
rare hyaline cast. Systolic blood-pressure 160. Patient was jaundiced. 
It now seemed certain that his bleeding was due to chronic nephritis. 
He was placed under the care of a medical man and was not seen by me 
again. On May 1, 1917, he died of nephritis. 



2i8 AN OUTLINE OF GENITO-URINARY SURGERY 

Renal Hematuria Due to Focal Nephritis or to Varix of the Papilla — 
So-called "Essential Hematuria." — C. B. G., male, bookkeeper, age 
thirty-six. Gonorrhea eight years previously. Three years ago had 
pains in the back, and later passed blood in the urine. Cystoscopy at 
this time showed that the blood came from the right kidney. A guinea- 




Left Right 

Fig. 58. — Right renal hematuria. No definite abnormality of pel- 
vis of either kidney, although upper calyx of right kidney is somewhat 
widened. (ic-Ray by Dr. L. B. Morrison.) 

pig inoculated at the time was negative for tuberculosis. After six weeks 
the bleeding stopped, not to recur again until one week ago. a;-Rays 
show urinary tract negative. :r-Ray of chest shows well-healed lesion of 
glands about root of right lung. November 20, 1917, blood-pressure 
164 systolic, 112 diastolic. November 22, 1917, systolic 135. Lungs 



DISEASES OF KIDNEYS .\ND URETERS 219 

and heart normal. Urine clear; sp. gr. 1006; albumin slightest possible 
trace; sugar 0. Sediment: a few blood-cells; occasional leukocyte. 

Cystoscopy December 1, 1917: Right ureter catheterized to kidney. 
Passage of catheter followed by a gush of bloody urine from ureter. On 
left side no catheter would pass farther than 5 cm. Both sides were in- 
jected with thorium. Pyelograms show^ed normal pelves. The normal 
outline of the right kidney pelvis seemed to us to exclude tumor of the 
kidney as a cause of hematuria (Fig. 58). H3-pernephroma which caused 
bleeding three years before should have b}" this time caused abnormality 
of the pelWs. Diagnosis seemed to us to be either early chronic nephritis 
or bleeding from a varix in one of the renal papillae. 

Pyuria practically always means infection. A few leuko- 
cytes may occur in aseptic stone or in hj^ernephroma with- 
out denoting infection. With pyuria, the bacteriology of the 
urine should be investigated, it being especially important to 
rule out tuberculosis. Colon bacillus or coccal infections, 
it must be remembered, may complicate stone, tumor, or 
hydronephrosis. 

2. Pain is a symptom of value, which, properly inter- 
preted, often leads to a correct diagnosis. Renal pain is of 
two kinds — the dull, hea\y lumbar ache, which means dis- 
tention of the capsule (Squier), and is caused by renal reten- 
tion or by swelling of the renal parenchyma; and the sharp, 
cutting, intermittent pain, known as "renal or ureteral colic," 
which denotes a spasmodic hyperactivity on the part of the 
smooth muscle of the pelvis and ureter. The latter pain 
radiates along the course of the iliohypogastric and ilio-in- 
guinal nerves — that is, it is referred to the bladder, the labia, 
the testicle, and the thigh. The dull, constant pain is caused 
by a beginning hydronephrosis (late hydronephrosis usually 
does not cause pain) or by acute inflammation of the renal 



520 AN OUTLINE OF GENITO-URINARY SURGERY 

cortex. Renal colic is caused by the effort of the pelvis and 
ureter to express urine past a sudden obstruction, or to ex- 
press clots, masses of pus, or calcuH. The irritation of the 
mucosa by sharp crystals is sufficient to cause renal colic; in 
such an event the urine generally contains blood, which points 
to an actual wounding of the mucosa. 

3. Disturbances of urination may be the only symptoms 
of disease of the upper urinary tract. The occurrence of 
frequency as the only symptom of renal stone has been demon- 
strated. Renal infection, especially tuberculosis, habitually 
makes itself first felt through disturbance of bladder func- 
tion. Of course the urinary examination will show the 
presence of infection in nearly every case. I have seen a 
pyonephrosis with occluded ureter which gave no signs in the 
urine nor pain in the kidney, but was the only apparent 
cause of bladder irritability. 

4. Fever is simply another sign of infection, and the oc- 
currence of fever and pyuria together with renal pain or renal 
tenderness means renal infection. The infection may be 
simple or may be a complication of another lesion. 

5. Abdominal Tumor. — A painless abdominal tumor may 
be discovered by the patient himself or by his physician 
during routine physical examination. The first obstacle in 
the way of making a diagnosis may be the difficulty of know- 
ing whether the tumor is of renal origin or not. Abnormality 
of the urine, such as hematuria or pyuria, casts strong sus- 
picion upon the kidney, but if the urine is normal the question 
can be decided only by cystoscopic examination. In obscure 



DISEASES OF KIDNEYS AND URETERS 



221 



cases pyelography is of very great assistance, as it shows the 
situation of the kidney -with regard to the tumor, and the 
presence of abnormahties in the shape of the kidney pelvis. 
The same procedure which tells whether or not the tumor is 
renal will give the diagnosis if the tumor is of the kidney. 




Fig. 59. — Pyelogram made with thorium. The outline of the upper 
half of the renal peh'is is distinctly abnormal and suggests the presence 
of a tumor. (a:-Ray by Dr. L. B. Morrison.) 



Hypernephroma Diagnosed by Pyelography. — Miss H., a well-pre- 
served woman of seventy-two, whose past history was unimportant, had 
noticed for about four months that there were times when the urine 
contained blood. The attacks of hematuria would last for several hours, 



222 AN OUTLINE OF GENITO-URINARY SURGERY 

sometimes as long as all day, and would disappear as suddenly as they 
arrived. She had lost some 15 pounds in weight. 

On examination, the left kidney was easily palpable and felt somewhat 
enlarged. The urine sometimes contained blood, at other times was 
normal. I was asked by Dr. E. H. Risley, whose patient she was, to in- 
vestigate her renal condition. 




Fig. 60. — H>'pernephroma. A pyelogram of this kidney is shown in 
Fig. 59. Note the mass of tumor tissue obliterating the upper part of 
the pelvic cavity, as is suggested by the pyelogram. 



Cystoscopy, December, 1917: The bladder was normal. Divided 
functional test showed prompt output of phthalein from both sides; the 
amount excreted appeared about equal. A pyelogram showed definite 
deformity of the upper part of the renal pelvis (Fig. 59), because of which 
the diagnosis of hypernephroma was made. 



DISEASES OF KIDNEYS AND URETERS 223 

Dr. Risley removed a somewhat enlarged, knobby kidney (Fig. 60). 
When split open, the upper half was seen to be composed of tumor tissue. 
A tongue of new growth projected into the upper part of the pelvis, and 
was the cause of the deformity shown in the pyelogram. Microscopic 
examination showed the tumor to be hj-pernephroma. The patient made 
an uneventful convalescence. 

Without cystoscopic examination it is at times impossible " 
to say whether a tumor unaccompanied by urinary abnor- 
mahties is of the kidney. The situation of such a tumor be- 
neath the ribs, and the fulness in the costovertebral region 
which is evident upon bimanual palpation, suggests a renal 
origin, but cysts of the liver upon the right and tumors of the 
spleen upon the left may be indistinguishable from renal 
tumors by ordinary methods of examination. 

Differential Diagnosis of Abdominal Tumor. — M. W. S., age twenty- 
six, electrician. Case of Dr. Hugh WilHams at the Massachusetts Gen- 
eral Hospital. No. 210,403. September 8, 1916. Always well and 
strong. Six years ago was sick for about three weeks with jaundice. 
Three months ago noticed a lump in the left side of the abdomen just 
below the ribs; it has grown no larger since then, and has caused no pain. 
Physical examination negative save for smooth, non-tender, rounded 
tumor, which protrudes from under left costal margin and extends dowTi- 
ward as far as the umbiHcus. No notch could be felt. The mass seemed 
definitely fluctuant. Urine was normal. Leukocytosis 28,000 and 
15,000. PohTiuclears 84. Lymphocytes 16. Red cells normal. Sur- 
gical and medical consultants expressed their belief that the tumor was 
due to (1) polycystic kidney, (2) cystic kidney. Cystoscopy: Bladder 
normal. Urine from left kidney showed a few red blood-cells and leuko- 
cytes. Radiogram (Fig. 61) showed the ureter catheter curving across 
spine to right side, and back again to left side. Renal pelvis was low. 
Genito-urinary consultation: "Cystic tumor pushing kidney down." 
Total function: One hour, 45 per cent. Echinococcus complement- 
fixation test and Wassermann negative. 

Operation was done by Dr. Hugh Williams. A cystic spleen was re- 
moved, which the pathologist reported as dermoid in type. Uneventful 
recovery. 



224 AN OUTLINE OF GENITO-URINARY SURGERY 

The feeling of fluctuation in such tumors is not a safe 
guide to their character. Soft, congested solid tumors, such 
as some hypernephromata, may feel less solid than do some 
cystic tumors tense with fluid. 

The presence of blood in the urine combined with a tumor 
in the renal area is so suggestive of hypernephroma that 




Left Right 

Fig. 6L — Radiographic catheter in ureter. Kidney pushed down by 

tumor of spleen (Mass. General Hospital). 

operation should be thought of at once. Cystoscopy should 
be done to ascertain from which side the blood is coming, as 
otherwise one cannot be sure that the hemorrhage is not 
caused by bladder tumor, stone in the other kidney, or some 
other cause not connected with the tumor in the flank. The 



DISEASES OF KIDNEYS AND URETERS 225 

finding in the urine of a slightest possible trace of albumin and 
a low specific gravity, especially if these are accompanied 
by an increased blood-pressure, suggest that the tumor may 
be a polycystic kidney. In this case the tumor may be bi- 
lateral, with palpable nodularities of the surface. 

Variability in the size of the tumor suggests hydroneph- 
rosis, and this suspicion is upheld by a definite history of 
the passing of large quantities of urine coincident with the 
diminution of the tumor. It is to be remembered that such 
a kidney occasionally bleeds following sudden evacuation of 
its contents. 

6. The symptom-complex which at first sight seems least 
likely to be due to kidney disturbance, but which, in reality, 
is frequently the sign that awakens the patient to a knowledge 
that something is T\Tong, is the symptom-complex of renal 
insuflaciency. This manifests itself through the patient's 
general condition and particularly through his digestion. 
Afflicted by headache, a sense of malaise, flatulence, loss of 
appetite, and nausea, the patient determines to see his doc- 
tor and get a "tonic." If his physician does a general phys- 
ical examination and examines the urine he will probably be 
able to render a real serxdce. 

Renal s\Tnptoms of this character are most frequently 
secondary to obstruction in the lower urinary tract. Tabet- 
ics, prostatics, individuals with diverticula w^hich press upon 
the ureters, may not realize they are sick until the signs of 
diminished kidney activity appear. Rectal examination 
will reveal the presence of any important amount of residual 
15 



226 AN OUTLINE OF GENITO-URINARY SURGERY 

urine, and the detection by abdominal percussion of vesical 
enlargement leads one to the investigation of that portion of 
the urinary tract. 

Bilateral polycystic disease must be borne in mind, and, 
of course, chronic nephritis of non-surgical types must be 
excluded. Extensive destruction of renal tissue by stone or 
infection may develop so insidiously that the victim is un- 
aware of his condition until the signs of uremia appear. 

"Essential hematuria" is one of those vague terms used 
to describe a condition which we do not thoroughly under- 
stand. Hematuria not due to stone, tumor, or infection 
occurs not infrequently. Two explanations have been ad- 
vanced. Hurry Fenwick believes that many of these cases 
are due to varicosities upon the papillae. Others hold that 
the bleeding is due to areas of sclerosis in the kidney — the 
so-called Weigert kidney. The hemorrhage is painless, in- 
termittent, and at times profuse. It occurs usually in per- 
sons who are in the second half of life, and may be severe 
enough to cause serious anemia. Even if this is not the case, 
every renal hematuria must be studied by function test and 
pyelography or else subjected to an exploratory operation. 
The danger of overlooking an early hypernephroma is too 
great to permit of "watchful waiting." An absolutely normal 
pelvic outline, with no enlargement of the kidney, may justify 
a diagnosis of "essential hematuria," without actual explora- 
tion of the kidney, but, especially if the hemorrhage is at all 
profuse, operation is the safest procedure. The kidney need 
only be delivered and palpated; nephrotomy is unnecessary. 



DISEASES OF KIDNEYS AND URETERS 227 

If the bleeding should prove to be that of ''essential hema- 
turia," and not due to tumor, the operation is not in vain, 
for the bleeding of essential hematuria is practically always 
cured by decapsulation of the kidney. 

Renal Hematuria Cured by Decapsulation. — P. J. F., age forty, single. 
Admitted to the ]\Iassachusetts General Hospital July 1, 1915, with a 
diagnosis of "essential hematuria," probably due to varix. 

The past history was negative. His present trouble began about two 
and a half months ago, when he fell from the arm of a chair, striking his 
left side against a step. On the following day he noticed that he was 
passing bloody urine, and this has continued up to the present time. 
Urine more bloody in the morning than toward the end of the day; on 
several occasions he passed clear urine in the afternoon. Has never had 
any frequency, pain, or burning sensation, and feels perfectly well. 

Physical examination showed a weU-developed and nourished man. 
General physical examination negative. Urine: Bloody; acid; specific 
gra\-ity 1020; albumin trace; sugar 0. Sediment: ]\Iany red and white 
blood-cells. Cultures negati^•e. .r-Ra}^, pelWs injected with 2 c.c. of 
argentide, showed a low right kidney; pehds not completely filled. July 
3d, c\'stoscopy: Left catheter passed easily to pehds; right passed easily 
to ^\ithin 2 inches of the kidney, where it stuck; 1 c.c. phenolsulphone- 
phthalein injected into vein. Appearance time on left four and a half 
minutes, on right seven minutes; 20 per cent, on left, 6 per cent, on right, 
excreted in fifteen minutes. No leakage into bladder. Preoperative 
diagnosis: Tumor of kidney, with obstruction of pehic outlet. 

July 3, 1915, operation: 5-inch oblique kidney incision. A normally 
placed kidney freed and deUvered. There were unusually dense ad- 
hesions between lower pole and ureter. These were thoroughly freed. 
Careful palpation of kidney showed no suggestion of tumor or stone. 
Capsule stripped. Fixation not done, as kidney fell of its own weight into 
a better position than could be obtained by fixation. Rubber tissue 
drain. 

Convalescence uneventful, and on July 15th the patient was discharged 
relieved. February 18, 1918, the patient reported for examination. He 
had had no hematuria since operation. Urine was clear, no albumin. 
Blood-pressure was normal and the kidney was not palpable. 

Summary. — Unilateral renal hematuria of two and a half months' 
duration cured by decapsulation and freeing of reno-ureteral adhesions. 
Diagnosis is a little in doubt. Radiograph suggested pelvic retention, 



225 AN OUTLINE OF GENITO-URINMIY SURGERY 

but bleeding may have been due to a varix of the papilla. The findings 
at operation do not explain decreased renal function from diseased kidney. 

Decapsulation in Nephritis. — Decapsulation of the kid- 
ney as a means of arresting the progress of nephritis was per- 
formed by Edebohls in 1898. He believed that the increased 
and adequately maintained blood-supply to the kidney es- 
tabUshed by the operation leads to gradual absorption of the 
interstitial or intertubular inflammatory products and exu- 
date, thus permitting the re-establishment of a normal circu- 
lation. Of 102 patients operated upon by him, 33 were cured 
and 11 improved. Experimental and pathologic evidence 
has, as a rule, not sustained Edebohl's contention. Despite 
this fact, as careful an observer as John Lovett Morse, basing 
his opinion upon a number of carefully followed cases of 
nephritis in children upon whom Edebohl's operation had 
been done, comes to the conclusion that ''no child ill with 
acute nephritis should be allowed to die without giving it the 
advantage of the chance offered by this operation. It may 
prolong life for considerable periods in a not inconsiderable 
number of cases of chronic nephritis, and very possibly, in 
lare instances, result in cure. It should, therefore, always 
be considered in all cases of chronic nephritis in childhood 
which are not responding reasonably well under medical 
treatment." 

Nephroptosis, or movable kidney, is a very common con- 
dition, especially in women. The right kidney is more liable 
to be affected than the left. Abnormal mobility sometimes 
follows a rapid loss of weight, and in that case is caused by 



DISEASES OF KIDNEYS AND URETERS 



229 



the absorption of fat from around the kidney. At other 
times it is the result of faulty posture, and is due to (1) gen- 
eral ptosis of all the abdominal organs, (2) the straightening 
out of the lumbar curve, and consequent obliteration of thf 
shelf upon which the kidney ordinarily rests. 




Fig. 62. — Showing normal position and outlines of kidneys. Patient 
standing (Mass. General Hospital). 



It is not at all unusual to be able to palpate the lower part 
of the kidneys in women ; mobility of that degree can hardly 
be called abnormal. When the kidney descends below the 
costal margin and can be palpated in its entirety, it may be 
said to be abnormally mobile. Even such mobility, however, 
does not usually cause symptoms or do any particular harm. 



230 AN OUTLINE OF GENlTO-URlNARY SURGERY 

The ureter, like the intestine, can propel its contents in spite 
of curves and kinks, unless at some one of the kinks it is 
adherent. When the ureter kinks over a band of adhesions 
or an aberrant vessel, the free passage of urine is, of course, 
obstructed, and renal retention, with its various symptoms, 
results. 

Movable kidneys sometimes cause a dull ache, presumably 
from the drag upon the renal mesentery or from the conges- 
tion caused by kinking of the renal vein. The t3T)ical pain, 
however, is excruciatingly sharp, the pain of sudden disten- 
tion of a renal pelvis which cannot empty itself, and is known 
as "Dietl's crisis." If attacks of renal pain can be relieved 
by pressing the kidney upward into position or by a change 
of posture, this fact is of much diagnostic value. 

There are many cases of pain, apparently of renal origin, 
associated with normal urine and negative x-ray findings. 
Most of them are never explained. To attach the blame to a 
condition of mobility demands more than the mere fact that 
the kidney descends somewhat on inspiration. There must 
be evidence of pelvic dilatation in a pyelogram, there must be 
reproduction of the pain when the renal pelvis is distended, 
and there must be ruled out such, possible causes of pain as 
gall-stones, spinal lesions, occupational strains, and so forth. 

The operation for the relief of renal mobility is nephropexy. 
The capsule is stripped and its four corners are sutured to 
surrounding muscles, thus suspending the kidney in a sling. 
If done in properly selected cases the operation gives great 
relief. If done in the face of general ptosis or faulty posture 



DISEASES OF KIDNEYS AND URETERS 231 

it will be followed by a return of the kidney to its old habits. 
Some years ago many kidneys were operated upon for mobil- 
ity. Today, with better diagnostic measures at hand, we 
do the operation less frequently. 

Movable Kidney — Nephropexy. — W. P. P., age forty-four, single. 
Admitted to the INIassachusetts General Hospital September 8, 1916. 
Diagnosis : Nephroptosis . 

Past History. — Chancre twenty-two years ago; rash two months later; 
treatment for three years. Gonorrhea four years ago; discharge for three 
months. Occasionally since then there has been slight urethral dis- 
charge. 

Present Illness.— Twelve months after patient became infected with 
gonorrhea he had a sense of pressure in the region of the right kidney. 
Since then this sense of pressure, rather a dragging do^vn feeling, has 
• bothered him constantly. There has been no severe pain, no nausea or 
vomiting. No stones or gravel passed with urine; no hematuria, dysuria, 
or frequency. Pain comes without strain or exertion and is not affected 
by motion; always present when patient is standing, disappears on lying 
down. 

Physical examination showed a well-developed and nourished man. 
Abdomen full, tympanitic throughout, except in upper right quadrant, 
where there is dulness. Right kidney felt 10 cm. below costal margin 
when patient is upright, 2 cm. below when reclining. Edge is smooth, 
about normal in size and shape, tender on pressure. Urine: Clear, acid; 
no albumin; no sugar; rare pus-cell in sediment. Renal function: Ap- 
pearance time eight minutes; first hour 30 per cent.; second hour 20 per 
cent. Cystoscopy: Moderate amount of pain and intolerance. jMucosa 
normal, ureters normal, but orifices are at such an angle that catheter was 
passed with considerable difficulty; 9 c.c. of methylene-blue injected into 
right pelvis before there was a return flow. Argentide (4 c.c.) injected for 
a;-ray, causing severe renal colic. Jc-Ray: Outlines of kidney are dis- 
tinctly seen, appearing normal in size and shape. Pelvas of kidney not 
sufficiently filled to show outlines. 

Operation (September 9, 1916). — Vertical lumbar incision on right side 
carried forward at lower end. Very thick musculature made dehvery of 
kidney difficult. A movable kidney of normal size was freed. Several 
cysts on anterior surface punctured. No stone felt. Kidney capsule 
split longitudinally and stripped; four corners tied with Pagenstecher and 
sutured to adjacent musculature. Rubber tissue drain. 



232 AN OUTLINE OF GENITO-URINARY SURGERY 

Convalescence uneventful. Patient discharged relieved September 
24, 1916. 

Summary. — A case of very movable kidney in an unusually muscular 
man who had no general ptosis. Nephropexy done. No reason for 
mobility found. 

Renal Infections. — Aside from tuberculous infections of 
the kidney, which will be considered in Chapter XIII, the 
great majority of renal infections (70 or 80 per cent.) are due 
to the colon bacillus. Staphylococcus and streptococcus in- 
fections are next in frequency, and then come the rarer infec- 
tions by the Bacillus mucosus capsulatus, gonococcus, and 
Bacillus pyocyaneus. 

The route by which infection takes place has been the sub- 
ject of conflicting opinions. Definite evidence has been pre- 
sented, proving that in some cases at least colon infections 
of the kidney occur through the medium of the blood-stream 
(Cabot and Crabtree). Other observers have presented ex- 
perimental evidence that infection may ascend by the 
lymphatics of the ureter. The latter theory explains certain 
sequences found in clinical conditions, such as renal infec- 
tions following infection of vesicles on the same side, better 
than does the former. The evidence for the theory of the 
hematogenous route is so incontrovertible that it also must be 
accepted. The truth probably is that both routes exist, and 
that sometimes one, sometimes the other, is employed by the 
bacteria which invade the kidney. 

Infection ascending by means of the column of fluid con- 
tained in the lumen of the ureter is impossible except in cases 
of urethral obstruction, in which, as a result of back pressure, 



DISEASES OF KIDNEYS AND URETERS 233 

the ureterovesical valves become incompetent and the entire 
upper urmary tract becomes distended with stagnant, infected 
urine. 

In experimental animals a traumatized kidney is more sus- 
ceptible to infection, and this undoubtedly holds true in man. 
In man, trauma of the kidney is caused by stone or by dis- 
tention with urine, such as occurs through blocking of the 
ureter .or through obstruction at or below the bladder neck. 
When the distention is suddenly relieved, as by complete 
catheterization of an overdistended bladder, a congestion of 
the kidney follows, which reduces the resistance of that organ 
to infection. Autopsy on cases of prostatic obstruction who 
have died following operation show these lesions. In a case 
of this sort, a man who died two weeks after his operation, 
the pathologist reported as follows: "Combined weight of 
kidneys 230 grams. Capsules strip, leaving surface which 
shows many irregular areas of depression with smaller and 
larger mound-like masses of kidney tissue resting between 
them. In many places the surfaces are dotted over with 
minute to small dirty yellowish areas which yield in instances 
frank pus. The section surfaces of the cortex show here and 
there small, pale yellowish areas and slender streaks, some of 
which yield pus. The pelves are considerably dilated and 
contain much thin, cloudy, purulent fluid material. The 
mucosa is reddened and coated in places with dirty, yellow- 
ish, shaggy, fibrinopurulent material. Ureters considerably 
dilated. The mucosa shows in places areas of reddening." 
The ability of the normal kidney to filter out bacteria with- 



234 AN OUTLINE OF GENITO-URINARY SURGERY 

out harm to itself has been demonstrated a number of times. 
If the kidney is damaged, as occurs when a calculus rubs off 
the superficial layers of the pelvic mucosa, these wandering 
bacteria secure a foothold. 

It is possible that every acute infection of the kidney ac- 
companied by fever and pain involves not only the pelvic 
mucosa, but ascends by way of the lymphatics into the con- 
nective tissue of the kidney between the tubules (pyelo- 
nephritis). In certain cases the infection undoubtedly 
starts in the parenchyma, and later involves the pelvis. 
Colon infections involving the renal parenchyma almost 
always quiet down; infections by the cocci are liable to form 
abscesses or to run so fulminating a course that operative 
interference is necessary to save the patient from the over- 
whelming infection (acute hematogenous kidney). 

Given, then, an acute infection of the kidney, the progno- 
sis of that particular case is made much simpler if the medical 
attendant knows what organism is at the bottom of the 
trouble. If it is the colon bacillus, he may expect the attack 
to quiet down; if the staphylococcus or streptococcus, he 
must be prepared for a fulminating infection demanding 
radical treatment. As the colon bacillus quickly gets into 
the tubules, pus in the urine occurs early; the coccus infections 
are more concerned with the intertubular tissues, and pus in 
the urine is rather a late occurrence. Blood-cells, from the 
intense congestion, appear early, and the presence in the urine 
of blood-cells and cocci is of great value in helping make the 
diagnosis between an acute hematogenous kidney and an acute 



DISEASES OF KIDNEYS AND URETERS 



235 



appendix. Blood alone in the urine may accompany an 
attack of acute appendicitis if the appendix overlies the 
ureter. 

The particular measures to be adopted must be determined 
at operation. For the less severe cases decapsulation of the 
kidney and drainage of the pelvis will care for the infection. 
In the more fulminating type, when the kidney is full of 
abscesses, nephrectomy is indicated. 

In the treatment of acute renal infection in prostatics 
or tabetics proper drainage of the bladder is imperative. 
For all cases of renal infection, rest in bed, forced fluids, free 
catharsis, and bland, light diet are indicated. Hot applica- 
tions over the affected kidney are soothing. 

If the infection is due to the colon bacillus, hexamethylen- 
amin in large doses — 15 grains three or four times a day — is 
very valuable. In coccus infections it is impossible to reach 
the bacteria in the tissues by any drug excreted through the 
tubules, so that not much is to be expected from the admin- 
istration of medicines. The passing of large quantities of 
water — 100 to 200 ounces a day — w^ill be found valuable in 
quieting the infection, and may be increased by the use of 
a mild diuretic. 

Pyelitis of Pregnancy. — Acute infection of the kidney, 
manifested by temperature, pyuria, and renal tenderness, 
may occur at any time after the uterus becomes large enough 
to press upon the ureters where they cross the pelvic brim. 
It may come on during the puerperium. Although this 
process is termed "pyelitis," it is probable that, at least in 



236 AN OUTLINE OF GENITO-URINARY SURGERY 

the early period of the infection, there is an invasion of the 
renal lymphatics as well. The organism is nearly always 
the colon bacillus; the infection may be really acute or may 
be an exacerbation of one of long standing. The patient 
should, of course, be put to bed, given forced fluids and hexa- 
methylenamin, 15 grains, three times a day. Under this 
treatment the infection will usually subside. Less frequently 
it will continue and will destroy the kidney. If, therefore, 
the temperature and pain do not subside within two or three 
days, more active measures should be instituted. Of these, 
the first to try is lavage of the renal pelvis by means of the 
ureteral catheter. The estabhshment of better drainage 
through the washing out of inspissated purulent material 
from pelvis and ureter is probably the real reason for the 
good results which may follow pelvic lavage. 

Pyelitis of Pregnancy Treated by Lavage of the Renal Pelvis. — Mrs. 
W. R. T. Age twenty-five. March 17, 1917. Primipara; delivery 
three weeks ago. After delivery had trouble voiding and was catheter- 
ized. Nurse, supposed to do this every eight hours, did not empty blad- 
der completely at any time. It became infected and temperature ele- 
vated. Pain in right side. No history of previous urinary infection. 

Temperature today 105° F, Right kidney slightly tender; left not 
tender. Urine very cloudy, with heavy precipitate of pus; colon bacillus 
present. Cystoscopy: Base of bladder edematous. After some time a 
No. 5 ureter catheter was passed up right ureter. Cloudy urine, contain- 
ing pus and colon bacilli, obtained. Pelvis washed with silver nitrate 
(1 per cent.). Flakes of pus could be seen issuing about catheter as fluid 
was injected. Patient had no reaction following cystoscopy. Next 
evening temperature 103° F., then fell to normal and remained so. 

April 12th: Feels well, but rather weak. Catheter specimen very 
s'ightly hazy; no albumin. Sediment: Some pus and epithelial cells; a 
few colon bacilli. Has been on hexamethylenamin, 45 grains a day. 
Some bladder irritation. Culture shows no growth. Patient has pain 



DISEASES OF KIDNEYS AND URETERS 237 

as bladder is emptied, but no frequency. Hexamethylenamin reduced to 
7^ grains three times a day. 

April 25th: Urine clear and clean. No growth. Sediment: Very few 
red blood-cells. On April 27th the urine was clear and clean, with no al- 
bumin. Sediment negative. Kidney not palpable. 

August 17, 1917: Patient had a chill and an attack of pain in the right 
costo\-ertebral angle yesterday. Today feels perfectly well. Examina- 
tion revealed no tenderness. Urine clear and clean; no albumin. Sedi- 
ment negative. 

If two or three irrigations of the renal pelvis fail to allay 
the process, one must consider either emptying the uterus 
or draining the kidney. Nephrotomy can be done without 
necessarily bringing on labor, and is sure to relieve the situ- 
ation. Emptying the uterus will almost certainly relieve the 
kidney, but the possibility that it may not do so, and may 
therefore be an unfruitful sacrifice, favors the direct attack 
upon the kidney. 

Pyelitis of Childhood. — Another rather distinct form of 
pyelitis is that which occurs in children, especially in girls. 
The child may run a temperature of 103° or 104° F., accom- 
panied perhaps by chills. Many cases, however, have only 
a very slight rise of temperature. There may be no localizing 
symptoms whatever, or there may be tenderness in the flank 
and lumbar region. The diagnosis depends upon the finding 
of pus or bacteria in the urine. Pyuria may not develop at 
first. Bacteriuria may be the only abnormality. 

The prognosis as to life is good; spontaneous cure occurs 
in many acute cases. In others the infection persists for 
years as a low-grade colon bacillus pyelonephritis punctuated 
by exacerbations, which slowly destroys the kidney. The 



238 AN OUTLINE OF GENITO-URINARY SURGERY 

pelvis becomes dilated, the cortex thinned. This process 
may be without symptoms until some new condition, such as 
pregnancy, supervenes. Then the old infection flares up, 
and investigation shows a practically useless kidney, a mere 
shrunken shell of scar tissue in which the colon bacilli are 
firmly established. 

The treatment of acute pyelitis in children consists in 
confinement to bed, free catharsis, much water, and hexa- 
methylenamin. This drug may be given in 10-grain doses 
every four hours, six doses being given during twenty-four 
hours. Many writers believe the best treatment consists in 
keeping the urine alkaline, and do not use hexamethylenamin 
at all. 

Others have had good results from alternating the reaction 
of the urine. High vegetable and fruit diet tends to produce 
alkaline urine, high protein diet (meat and eggs) keeps it acid. 
Potassium citrate or sodium bicarbonate is given for a few 
days, then omitted for a few days. Whatever the medica- 
tion, the essential points in the treatment are rest in bed 
and the washing out of the kidney pelves by the ingestion of 
much fluid. 

After the attack has cleared up, the patient should be kept 
on hexamethylenamin until the urine contains no pus and no 
bacteria. Even after that point, observations on the condi- 
tion of the urine should be made for several months, in order 
to be sure that the infection has died out. 

Sequelae of Pyelitis. — In the course of a few weeks the in- 
fection either clears up, becomes chronic, or destroys the kid- 



DISEASES OF KIDNEYS AND URETERS 239 

ney. The continuation or progression of the infection is 
manifested by fever; dry, red tongue; septic appearance; 
high white count and tenderness and enlargement of the 
kidney. The organ may be difficult to feel because of muscle 
spasm. 

Under these circumstances operative interference is de- 
manded. The question whether simple decapsulation, neph- 
rotomy, or nephrectomy is needed must be answered at 
the time of operation. 

If the infection apparently clears up, the physician, be- 
fore discharging the patient, should obtain negative cultures 
from the urine. These should be obtained a week or two 
after the patient has ceased taking hexamethylenamin. If 
this is not done, a condition of chronic bacilluria may con- 
tinue and menace the future health of the patient. 

If bacilluria continues, whether or not accompanied by 
pus, the cause of the infection should be investigated and, if 
possible, cleared up. As a rule, the continuation of renal in- 
fection indicates some underlying abnormality of the kidney, 
such as the presence of stone or deficient drainage of the 
renal pelvis due to kink of the ureter. There is some evi- 
dence to show that movable kidneys are unusually susceptible 
to chronic infection, though whether this is due to obstruc- 
tion to the outflow of urine or to congestion of the kidney is 
not known. 

Investigation of such cases means a^-ray to rule out stone, 
and cystoscopic stVidy of the renal pelvis. Is it dilated? Is 
there obstruction? Is the kidney one of those severely in- 



240 AN OUTLINE OF GENITO-URINARY SURGERY 

fected, partially destroyed organs from which recovery can- 
not be expected? These questions can only be answered by 
careful study with cystoscope, renal function tests, and per- 
haps pyelography. 

The treatment depends upon the cause. A thorough trial 
of hexamethylenamin must be made. In the case of infected 
movable kidneys associated with ptosis excellent results have 
been obtained in occasional instances by the use of proper 
ptosis corsets (Cabot and Brown). 

A persistent pyelitis in which no other definite lesion of 
the kidney is found may be cured by pelvic lavage. Simons 
has collected from the literature reports of 66 cases so treated, 
which were sufficiently studied to be of value. Of the 66, 
12 were cured by one lavage, 13 by two, 34 were cured only 
after three or more; 7 were not cured by lavage. Although 
the drug used is apparently unimportant, most urologists now 
employ silver nitrate in solutions varying from 1 to 5 per cent. 

The use of vaccines in the treatment of renal infections has 
not given very striking results. Hugh Cabot, in a series of 
30 cases of infection of the urinary tract, found that the use 
of vaccines was followed by improvement of the symptoms in 
more than half the cases, but had little effect on the bacteri- 
uria. 

If a definite abnormality, such as obstructed pelvic outlet, 
exists, it must be relieved by operation. If the kidney is 
of the sclerotic type, the parenchyma largely replaced by scar 
tissue, this fact will be indicated by a persistently low func- 
tion. Such a kidney should be removed, provided the other 



DISEASES OF KIDNEYS AND URETERS 24 1 

kidney is healthy. It not infrequently happens that the 
process is bilateral; in that case removal of either kidney, 
provided it has any function whatever, is not proper unless 
nephrectomy is made necessary by the trouble caused by that 
kidney. 

Bilateral Chronic Pyelitis. — M. A. L., masseuse, aged forty-five, was 
sent to me in IMarch, 1913, complaining only of foul urine. This condi- 
tion she thinks has always been present since she was fourteen years of 
age, at which time she had ''summer complaint." When eighteen years 
old she had a suprapubic cystotomy for stone, but none was found. She 
has never had pain in the bladder or in the kidney region. She has never 
passed blood, and has no frequency or burning on urination. She gets 
tired ver}- easily, but otherwise is in fair health. 

Physical examination : A tall, thin woman. Heart and lungs normal. 
Abdominal palpation shows that on deep inspiration the entire right kid- 
ney and the lower half of the left kidney are palpable. x-Ray shows no 
e\idence of stone. Both kidneys are distinctly outlined. The urine is 
cloudy and ammoniacal, with pus, and culture shows the colon bacillus. 
No residual urine. Cystoscopy shows a patchy cystitis. On the right 
side of lower lip of the internal meatus is a shallow diverticulum. Both 
ureters appear normal. The specimen from the right kidney shows epi- 
thelial cells and a negative culture; that from the left shows a few round 
and caudate cells and colon bacilli. 

On June 6 and 27, 1913, the pehis of the left kidney was washed 
with 1 : 1000 silver nitrate solution. On July 3d the right kidney became 
tender, although the patient was not sick. July 11th both ureters were 
catheterized. From the right much epithelium, no pus, colon bacilli. 
Urine from the left was hazy with bacteria. Phthalein test: The injec- 
tion was partly but not entirely intravenous. Color appeared on both 
sides in five minutes. The secretion from the right kidney was much 
better than that from the left. July 17th the right kidney pelvis was 
washed with silver nitrate (1 : 8000); the urine from that side being per- 
fectly clear. 

The patient was not seen again until January, 1915. She had gained 
5 pounds in weight. The urine was slightly hazy, but not foul or am- 
moniacal. Cystoscopy: Bladder clean. Urine from right, no albumin, 
pus, or bacteria; left hazy, no pus, many colon bacilli. Phthalein 1 c.c. 
intravenously. Color appeared on right in three minutes, on left in 
16 



242 AN OUTLINE OF GENITO-URINARY SURGERY 

seven minutes. There was much stronger color on the right, but so 
much leakage into bladder that estimation was not done. Both pelves 
washed with silver nitrate (1 : 5000), Capacity of left renal pelvis 42 c.c. 
In May, 1915, patient weighed 127 pounds — a gain of 7 pounds. 
Urine was still hazy, albumin slightest possible trace. She complained 
of feeling tired all the time, and had some vague pains in the joints. 
July 2, 1915, catheterization of ureters showed no pus from right, slight 




Fig. 63. — Chronic pyelitis with dilatation of both renal pelves. The 
radiographic catheter is in the left ureter (Mass. General Hospital). 
(See Case M. A. L.) 



growth of colon bacillus; from left, no pus, profuse growth of colon bacil- 
lus. Phthalein: Appearance time, right three minutes, left four minutes. 
In fifteen minutes 9 per cent, excreted from right, 4 per cent, from left. 
None in bladder. Urea: Right, 2.4 per cent.; left, 1.9 per cent. A brief 
course of autogenous colon vaccine was given, with definite relief of the 
pains in the joints. On February 8, 1916, pyelograms of both kidneys 
were made (Fig. 63). Both showed dilated pelves. December 8, 1916: 
Has had no treatment for past year. Weight 125 pounds. Complains of 



DISEASES OF KIDNEYS AND URETERS 243 

feeling tired, but is able to work. The urine is almost clear and the kid- 
neys seem distinctly less movable. 

This case is interesting from several points of view. It 
illustrates the gradual attenuation through which a colon 
bacillus infection will pass. At first the bladder reacted to 
the infection; later it recovered. The kidneys, with pelvic 
dilatation due probably to their mobility, could not throw off 
the infection. The right kidney suffered little, the left 
showed marked destruction of tissue, as evidenced by the 
functional test and considerable dilatation of the pelvis. 

Renal Retention. — Improper drainage of the renal pelvis 
may be due to the kinking of the ureter by adhesions between 
it and the lower pole of the kidney or by aberrant vessels which 
draw it into an acute angle. MobiHty of the kidney alone is 
not enough to cause obstruction to the urinary outflow; the 
ureter must be fixed at some point in its upper part in order 
to become obstructed. The chief symptom of obstruction 
of this t\-pe is intermittent pain, very severe, perhaps ac- 
companied by vomiting, and at times relieved by posture or 
by pressing the kidney upward with the hand. If the ob- 
struction is severe enough and frequent enough to cause hy- 
dronephrosis, the later phase is generally painless. 

Hydronephrosis Due to Aberrant Vessels. — ]\Iiss E. F., age twenty- 
three, was sent to me November 9, 1917. She had always been well until 
last winter. In February she had had tonsillitis, the follo\nng June had 
attacks of backache and fainting spells. Her doctor told her she had 
pyelitis. She lost 16 poijnds in two weeks. She has had constant back- 
ache since then, and ha? felt poorly whenever she attempts to go back to 
her work as clerk. Frequency not abnormal. .r-Ray negative for stone. 

November 23d she entered the Deaconess Hospital. Her evening 



244 AN OUTLINE OF GENITO-URINARY SURGERY 

temperature was 102.4° F. The urine was cloudy, containing much pus 
and colon bacilli. Cystoscopy showed a clean bladder and normal ap- 
pearing ureters. Both were catheterized, and from the right a dilute, 
hazy urine containing pus-cells, bacilli and cocci, was obtained; from the 
left a concentrated, hazy urine, containing blood and epithelial cells; no 




Fig. 64. — Renal retention, infected, due to kinking of ureter at pelvic 
outlet by aberrant vessels. (x-'Ray by Dr. L. B. Morrison.) 

bacteria or pus. Divided function, phthalein intravenously: Appear- 
ance time on right three minutes, left, five minutes; 8 per cent, on right, 
15 per cent, on left was excreted in fifteen minutes: no leakage into blad- 
der. The pelvis of the right kidney held 25 c.c. of thorium. The pyelo- 
gram showed an abrupt transition between a dilated pelvis and a narrow 



DISEASES OF KIDNEYS AND URETERS 245 

ureter (Fig. 64). The diagnosis of hydronephrosis wit±i ureter obstructed 
by aberrant vessels was made and the patient was operated upon. 

At operation a fairly sound kidney, with much extrarenal dilatation of 
peJN'is, was delivered. An aberrant artery and \ein were plainly \-isible 
extending from lower pole of kidney behind ureter toward middle line of 
body. These were tied and cut, and adhesions about the lower pole of 
the kidney were freed. The pelvis was opened, and a bougie passed down 
ureter, showing no further obstruction. A rubber tube was passed 
through cortex of kidney into the pel\-is. Edges of incision into pehis 
were loosely approximated and kidney replaced. Convalescence un- 
eventful. Two weeks after operation the tube was removed. A leak- 
age through the sinus stopped almost immediately. Temperature re- 
mained normal and the patient had no further pain. She gained rapidly 
in weight, and when last seen on January 15, 1918, the urine was clear 
and free from albumin. 

For the cure of renal retention operation is required, and 
may consist of freeing the ureter, of a plastic between pelvis 
and ureter, or if the kidney is largely destroyed, of nephrec- 
tomy (Fig. 65). 

Renal and Ureteral Stone. — Calculi in the upper urinary 
tract are formed by the deposition of crystals about a nucleus. 
This nucleus may consist of bacteria or other organic matter, 
but often stones form in otherT\'ise normal kidneys, and it is 
believed that they form upon nuclei composed of uric acid 
crystals cemented together by the colloid matters, such as 
pigment, which occur normally in urine. The commonest 
stones are those composed chiefly of oxalates; the next in 
frequency are the phosphatic stones. Calculi of uric acid 
or calcium urate are much less frequent. Rare stones are 
found composed of cystine or xanthin. Oxalate stones form 
rather slowly, as far as we can judge from the rarity of their 
recurrence. Phosphatic stones, on the other hand, may 



246 AN OUTLINE OF GENITO-URINARY SURGERY 

re-form within a year or two after removal, and in such cases 
are a serious menace to Hfe. For, although renal stone may 

"1 




Fig. 65. — Hydronephrotic kidney, split longitudinally. From a 
woman aged thirty who for two years had had severe attacks of pain in 
the region of this kidney. She was sent into the hospital with the diag- 
nosis of gall-stones. Radiograph showed an enlarged kidney containing 
two small stones. Ureter catheter drew off 40 c.c. of brownish fluid. 
Phthalein output was negligible. (Cambridge Hospital.) 

exist in a kidney for years without inflicting serious damage, 
it is sure to increase in size, and sooner or later will injure the 
kidney in which it is harbored. Stones damage a kidney in 



DISEASES OF KIDNEYS AND URETERS 247 

two ways: (1) By obstructing the outlet; (2) by causing le- 
sions in which infection gets a foothold. These two factors 
by working together, produce the typical pyonephrotic stone 
kidney — a mere shell divided into five or six compartments, 
each of which represents a calyx dilated to such an extent 
that the parenchyma has entirely disappeared. 

There are no typical symptoms of stone. Renal colic, 
which means the blocking of pelvic outlet or ureter, is always 
strongly suggestive, and if accompanied by blood in the 
urine it makes the diagnosis of stone very probable. It is 
not infrequent for renal stone to be absolutely painless. 

Renal Stone — Hematuria the Only Symptom. — M. M. W. Massa- 
chusetts General Hospital, No. 210,430. Age thirty-two, female, married; 
came to the Consultation Clinic with a history of having had blood in the 
urine for the past two months. Her past history was negative, and ex- 
cept for a dull ache in the region of the right kidney, which she felt after 
standing a long time, she had had absolutely no other symptoms. a:-Ray 
showed a large stone in the right kidney (Fig. 66). Its outline closely 
followed that of a renal pelvis. Urine from right kidney was bloody, that 
from left clear. Both showed a few colon bacilli. Divided function 
after intravenous phthalein showed on right, five minutes appearance 
time, 1.25 per cent, in fifteen minutes; left, three minutes appearance time, 
15 per cent, in fifteen minutes. Pyelogram on right suggested destruc- 
tion of the calices. Nephrectomy was done. The pathologist reported 
the calices considerably dilated, the pelvis pale, with small areas of hemor- 
rhage. It was filled with a branched calculus weighing 3.1 grams, and 
four small calculi weighing 0.8 gram. All were of calcium oxalate. 
Microscopic examination showed essentially normal kidney tissue, with 
areas of round-cell infiltration and fibrous thickening underlying the 
pelvic mucosa. 

The position and size of the stone must be demonstrated 
by :\:-ray before operation (Fig. 67). It should be borne in 
mind that about 10 per cent, of all stones are undetected by 



248 AN OUTLINE OF GENITO-URINARY SURGERY 

X-ray examination; the diagnosis must then be made by 
the cystoscopist with wax-tipped catheter and pyelogram. 




Fig. 66. — x-Ray showing renal stone. Only symptom was hematuria of 
two months' duration (Mass. General Hospital). 



In the great majority of cases of renal stone operative re- 
moval is indicated. There are certain cases of bilateral stone, 
however, in which the damage caused by removal would be 
greater than that caused by the stones themselves. Such 



DISEASES OF KIDNEYS AND URETERS 249 

cases call for a thorough knowledge of the patient and of 
the renal data, and for the exercise of much surgical 
judgment. 




Fig. 67. — Ureteral calculus, later removed through an extraperitoneal 
Gibson incision (Mass. General Hospital). 

Stones once formed, of course, cannot be dissolved, but if 
small, they may be passed. Ureteral stones as large as date- 
pits occasionally come through, whereas, in other instances, 
the tiniest stones may lodge in the ureter indefinitely. 



250 



AN OUTLINE OF GENITO-URINARY SURGERY 



The passage of ureteral stones can often be aided by the 
introduction of a ureteral catheter and the injection into the 
ureter of oil; sometimes it is necessary to slit the ureteral 
orifice through the operative cystoscopy A small ureteral 
stone, if not causing obstruction of the ureter, may be left 




Fig. 68. — Shadow apparently in course of ureter (Mass. General 

Hospital). 



for months without injury to the kidney, in the expectation 
that it may be passed. If a second x-tsly taken after several 
months shows that the stone has not moved, and cystoscopic 
measures have failed, it will be found that the stone is of the 
spiculated type, tightly grasped by the spasm of an irritated 
ureter. Operative removal is then the only way out. 



DISEASES OF KIDNEYS AND URETERS 251 

Ureteral Stone — Ureterolithotomy. — M. A. F., a woman of thirty-two, 
was sent to me on May 29, 1916, complaining of headache and of acute 
pain in the right back, radiating do\^•n the leg to the foot. In 1913 her 
appendix had been removed, following an attack of pain similar to the 
present. During the past year she had had eight attacks of pain begin- 




Fig. 69. — Same shadow with radiographic catheter in place. Shadow is 
seen to be ^ inch away from ureter (Mass. Genera) Hospital). 

ning in the right flank and radiating to pubes and to leg. Two attacks 
Cssre accompanied by some hematuria. 

General physical examination negative, except that the right kidney, 
was easily palpable on deep inspiration; not tender or enlarged. Urine 
was clear, with the slightest possible trace of albumin. Sediment showed 



252 AN OUTLINiE OF GENITO-URINARY SURGERY 

epithelial cells; no pus or bacteria; quite a number of red blood-cells. 
a:-Ray showed a shadow low in the right ureter (Fig. 70). June 6th, 
cystoscopy: A catheter was held up at about the situation of the shadow. 
Ureteral meatus was cut through the operative cystoscope; a No. 5 
catheter was passed to the kidney and 3 c.c. of gomenol oil was injected 
above the stone. June 8th she had a bad attack of renal colic. June 
19th the ureteral orifice was stretched through the operative cystoscope, 




Fig. 70. — Stone low in right ureter. Removed by ureterolithotomy, as it 
was firmly impacted. (ic-Ray by Dr. W. J. Dodd.) 

and an attempt made to seize the stone with nippers, but without suc- 
cess. 

September 12, 1916, as the patient had had several attacks of pain, and 
was nearly always conscious of discomfort, operative removal of the 
stone was decided upon. Through a right-sided Gibson incision, extra- 
peritoneal, the ureter was found moderately thickened and dilated. An 
oval, black stone was pressed up the ureter and removed through a small 



DISEASES OF KIDNEYS AND URETERS 253 

incision at the pelvic brim. One rubber tissue drain. The wound healed 
by first intention without urinary leakage. 

May 3, 1917: The patient has been South all winter and now feels 
very well She still has occasional pain in the right kidney, and the 
bladder urine shows the slightest possible trace of albumin; a number of 
pus-cells, and some colon bacilli; no blood or casts. Patient was put on 
15 grains of hexamethylenamin three times a day. June 11th the urine 
showed no albumin and only a rare pus-cell. July 6th, cystoscopy: No. 
6 catheter passed easily to the right kidney. Urine showed a few red 
blood-cells and epithelial cells; no pus at all. Pelvis washed with 1 per 
cent, silver nitrate. Since then the patient has had no symptoms refer- 
able to the kidney. 

During the renal or ureteral colic of stone the patient will 
get considerable relief from the application of heat, but severe 
attacks require a hypodermic injection of morphin. Atropin 
is supposed to be valuable through the relaxation of smooth 
muscle which it causes. There is experimental evidence to 
show that papaverin or the almost forgotten Sahli's mix- 
ture are more effective than morphin in relieving the ure- 
teral spasm. 

The prevention of the recurrence of stone after operation 
or after spontaneous passage consists in keeping the urine 
very dilute and in eating food which will decrease the excre- 
tion of the salt which was most concerned in the formation 
of the stone. 

In the case of oxalate calculi, which form slowly and which 
do not tend to recur, the urine should be watched for the 
occurrence of crystals of calcium oxalate. If the content of 
oxalates is found to be high, the patient should avoid foods 
which contain much oxalic acid, such as cabbage, spinach, 
asparagus, apples, and grapes. If this does not produce the 



254 AN OUTLINE OF GENITO-URINARY SURGERY 

oxaluria, other dietetic measures should be instituted. The 
physiologic chemistry of oxahc acid has not yet been thor- 
oughly determined, but there is evidence to show that gas- 
tric fermentation may increase the output of oxalic acid by 
the kidneys. 

Phosphatic calculi are particularly prone to recur. In 
those cases in which they re-form within a year or two after 
removal, the disease may well be called ''malignant." 

Recurrent Renal and Ureteral Stone. — G. S. A., an Albanian, twenty- 
three years of age, was admitted to the Massachusetts General Hospital 
May 23, 1914, because of attacks of right-sided pain. a;-Ray had showed 
a small shadow in region of right ureterovesical junction, and cystoscopy 
had confirmed this finding. By combined intra- and extra vesical routes 
I removed a small stone from the lower end of the right ureter. Except 
for a peri-urethral abscess convalescence was uneventful. 

After leaving the hospital he continued to have attacks of right-sided 
pain. Investigation showed that the lower end of the right ureter was 
strictured so tightly that not only did a filiform fail to enter, but indigo- 
carmin was not excreted from that side. December 19, 1914, I resected 
his right ureter 1 inch above its entrance into the bladder and reimplanted 
it. Convalescence was again uneventful. 

In September, 1916, he was seized with severe pain in the left side and 
ran a temperature of 102° to 103° F. x-Rays showed three small shad- 
ows low in left ureter, one larger shadow high in the left ureter, and one in 
the left pelvis. The left kidney was large and tender, and he was mani- 
festly very sick. I cut down upon his left kidney, which was large and 
congested, and removed a small stone from the pelvis and a larger one 
from the upper ureter. The kidney was. drained by a tube passed into 
the pelvis through the cortex. Good recovery, with prompt relief of 
pain and fever. Two weeks later I removed the three stones from the 
lower left ureter through a Gibson incision. 

Following this he was very well for about a year. He followed 
carefully the diet outlined on page 255. In spite of that, an :t-ray taken 
in the fall of 1917 showed a small shadow in the left kidney region. 
In July, 1918, after a careful "metabolic study which showed that the 
phosphatic content of his urine could be greatly reduced by diet, I 
removed this stone also. Good convalescence. 



DISEASES OF KIDNEYS AND URETERS 255 

The stones in such cases are frequently bilateral, and unless 
their formation can be stopped, surgery in itself cannot pre- 
vent the destruction of the kidneys. It has been shown that 
in such a case the phosphatic content of the urine may be 
three or four times the normal, and that this excess may be 
substantially reduced by proper diet. 

The foods to be avoided are eggs, milk, and fish. It has 
been shown that the ingestion of calcium carbonate pre- 
cipitates* the phosphates in the food as insoluble salts and 
thereby prevents their absorption. In addition to avoiding 
the above-mentioned foods, therefore, one should take a 
dram of calcium carbonate after each meal ; this has a consti- 
pating effect, but may be kept up for years without damage 
to the organism. 

Renal Tumor. — Pathologic enlargement of the kidney may 
be due to hydronephrosis, single cysts, cystic degeneration 
(so-caUed polycystic kidney), echinococcus cyst, or to the 
presence of a soHd tumor. The great majority of solid 
tumors of the kidney are of two types: (1) the embryonic 
tumor, which is discovered within the first three years of life, 
and (2) the hypernephroma of middle life, which appears 
generally between the ages of forty and sixty. Rarer tumors 
are papillomata of the renal pelvis, papillo-adenocarcinomata, 
flat-celled carcinomata, and sarcomata. 

Tumors of the embryonic type usually attract attention 
through the noticeable increase in size of the child's abdo- 
men. Blood in the urine clinches the diagnosis. The tumor 
is smooth, only slightly movable, and of elastic consistency. 



256 AN OUTLINE OF GENITO-URINARY SURGERY 

Pathologically, it consists of tissues derived from connective 
tissue and from epithelium; the former give rise to areas 
which resemble sarcoma; the epithelial tissue may present 
abortive attempts at the formation of tubules. What is left 
of the kidney is compressed into a crescent of renal tissue, 
borne upon one aspect of the growth. As soon as the tumor 
is discovered it should be removed. The prognosis is poor. 
Hypernephroma, the common renal tumor of adult years 
(80 per cent, of all renal tumors according to Wilson), was 
believed by Grawitz to develop from rests of adrenal tissue 
which were included by the kidney during its development. 
Stoerck attacked this theory and suggested that the neoplasm 
arose from regenerating convoluted tubules in the atrophic 
kidney. Wilson proposed the hypothesis that hypernephro- 
mata are derived from islands of nephrogenic tissue which 
have failed to become connected with the renal pelvis through 
the collecting tubules of the developing kidney. The com- 
monest symptom, occurring in 28 cases out of 32 (Wilson), 
is hematuria, which may appear before the renal enlarge- 
ment is perceptible to palpation. This is the time for opera- 
tion, so that the tumor may be removed, if possible, before 
metastases have taken place. The diagnosis is made by cys- 
toscopy, aided by separate renal function and pyelography. 
The encroachment upon the renal pelvis by the tumor causes 
a deformity of outline, sometimes characterized by the "spider- 
web" appearance, sometimes by an indentation in the pelvic 
outline (see Fig. 59). Once the diagnosis of hypernephroma 
is made, nephrectomy is indicated unless there is evidence of 



DISEASES OF KIDNEYS AND URETERS 257 

metastasis in lung or long bone, or the patient is cachectic 
and clearly overwhelmed by the malignancy of the growth. 

Polycystic kidney may give a characteristic knobby sensa- 
tion on palpation, and, as the process is bilateral, the total 
renal function is generally low. There are signs of chronic 
nephritis. Echinococcus cysts in the kidney give only the 
signs of tumor until they rupture. After that, daughter 
cysts appear in the urine. Pyelography shows that the 
tumor is renal. The blood should contain a definitely in- 
creased number of eosinophils and should give a positive 
complement-fixation test with echinococcus antigen. Neph- 
rectomy is indicated. 

Rupture of the kidney is generally caused by a fall in which 
the patient strikes his flank upon a sharp edge, or by a blow 
over the kidney. I have seen a kidney ruptured by a shrap- 
nel ball. The projectile had torn the pelvis away from the 
kidney and had wrapped the pelvis about itself. The 
prominent symptom of rupture of the kidney is hematuria. 
In some cases the extravasation of blood about the kidney 
fills the fatty capsule with clot and forms an easily palpable 
mass. 

If the bleeding is not severe the patient should be put to 
bed and kept absolutely quiet for from one to two weeks. 
A certain number of cases will get well with this treatment 
alone. Some will continue to bleed, will run a temperature, 
and will clearly demonstrate the necessity of operative inter- 
ference. Others, when seen at the very start, will show the 
signs of rupture impossible to heal. There may be great 
17 



258 AN OUTLINE OF GENITO-URINARY SURGERY 

shock or the signs of extensive hemorrhage. If the former, 
the patient's condition must be improved before operation 
is done. 

Operation usually consists of nephrectomy. Once in a 
while a kidney is found which may be sutured with some hope 
of getting a useful organ. The interposition of strips of 
muscular tissue between the torn surfaces acts as a hemo- 
static (Risley). 

Rupture of the Kidney — Nephrectomy. — A. L., a brakeman, twenty- 
four years of age, was caught between a freight car and a projecting roof. 
He was taken to the hospital at once. The first urine voided was clear, 
the second specimen was bloody, and the urine remained bloody for 
two weeks. The bleeding then apparently stopped. A few days later, 
after reaching for a glass of water, he had a very severe hemorrhage, 
fining the bladder with clot. I saw him two days later. His pulse was 
105 to 110, his temperature 100° to 101° F. His bladder seemed moder- 
ately distended (clots)' and he had a large mass in the right flank. Im- 
mediate operation was done. The fatty capsule was distended with 
blood-clot. The kidney was found to be torn almost in half and the pel- 
vis was split wide open. The peritoneum was opened and the other kid- 
ney palpated, after which the damaged kidney was removed. Conva- 
lescence was uneventful. 

Braasch, W. F.: Clinical Data of Multiple Cystic Kidney, Surg., Gynec, 
and Obst., 1916, xxiii, 697. 

Cabot, H.: Diagnosis and Indications for Operation in Early Hydro- 
nephrosis, Jour. Amer. Med. Assoc, 1913, Ix, 16-20. Treatment of 
Movable Kidney With or Without Infection by Posture, Boston 
Med. and Surg. Jour., 1914, clxxi, 369-373. Stone in the Kidney 
and Ureter. A Critical Review of 157 Cases, Jour. Amer. Med. 
Assoc, 1915, Ixv, 1233. 

Cabot, H., and Crabtree, E. G.: Classification and Treatment of 
Kidney Infections, Boston Med. and Surg. Jour., 1916, clxxiv, 780. 
Etiology and Pathology of Non-tuberculous Infections of the 
Kidney, Surg., Gynec, and Obst., 1916, xxiii, 495. 

Cunningham, J. H. : Acute Unilateral Hematogenous Infections of the 
Kidney, Trans. Amer. Assoc Genito-urin. Surg., 1912, vii, 145-169. 



DISEASES OF KIDNEYS .\XD URETERS 259 

EiSEXDRATH and K.\Lix: Role of Lj-mphatics in Ascending Renal In- 
fection, Jour. Amer. Med. Assoc, 1916, cxvi, 561. 

Geraghty, J. T. : The Treatment of Chronic Pyelitis, Jour. Amer. Med. 
Assoc, 1914, Lxiii, 2211-2214. 

Keyes, E. L., Jr.: Mechanics of Renal Infection, Lancet-Clinic, 1916, 
cxv, 121. 

Morse, J. L. : Edebohl's Operation in Nephritis in Children, Jour. Amer. 
Med. Assoc, 1917, Ixix, 525-530. 

Schmidt, L. E.: Nephrectomy During Pregnancy, Trans. Amer. Assoc. 
Genito-urin. Surg., 1915, x, 109-119. Echinococcus of the Kidney 
Trans. Amer. Assoc Genito-urin. Surg., 1915, x, 129-143. 

Smith, G. G.: Renal Stone, Boston Med. and Surg. Jour., 1917, cLxxvi, 
524^529. 

Smith, R. ]M.: Recent Contributions to the Study of Pyelitis in Infancy, 
Amer. Jour. Dis. Children, 1913, v, 273-278. 

Squier, J. B.: Renal Lithiasis, Amer. Jour. Surg., April, 1913. Renal 
Pain: Diagnostic and Clinical Significance, Trans. Amer. Assoc. 
Genito-urin. Surg., 1915, x, 265-282. 

Wilson, L. B.: The Embryogenetic Relationship of Tumors of the 
Kidney, Suprarenal, and Testicle, Ann. Surg., April, 1913. Hyper- 
nephromata, Old Dominion Jour. ]Med. and Surg., 1910, x, No. 4. 



CHAPTER XIV 
GENITO-URINARY TUBERCULOSIS 

The tubercle bacillus strikes the male genito-urinary 
tract chiefly at two points — the kidney and the epididymis. 
In the female renal tuberculosis appears as in the male; 
genital tuberculosis is less frequent than in the male, and has 
less to do with the urinary organs. 

Strictly speaking, tuberculosis of the genito-urinary tract 
is never primary, but depends upon the existence of a focus 
elsewhere in the body. This focus may be a single tubercu- 
lous gland, or may consist of extensive lesions of bone or lung. 
The route by which the kidney becomes infected has been in 
much dispute. Lawrason Brown has shown that the kidney 
can filter out tubercle bacilli presumably from the blood with- 
out damage to itself. That it sometimes fails in this, and 
suffers from the lodgment of bacilli in its own tubules, is one 
explanation of the method of infection. 

The lymphatic route is considered by some urologists to be 
the more probable. Brongersma showed that particles of 
dust could pass from peribronchial lymph-nodes against the 
stream to the juxta aortic nodes, and believed that either in 
this way, or from infected mesenteric nodes, the tubercle 
bacilli reached the kidney. In defence of his theory he pre- 
sented a number of cases in which the pulmonary and renal 

involvement were upon the same side. 
260 



GENITO-URINARY TUBERCULOSIS 261 

Kidney and Bladder. — Perhaps according to the route by 
which the bacteria reach the kidney, two types of lesions 
appear. One is the pelvic type, in which the pelvic mucosa 
is much involved, and the apices of the pyramids ulcerated 
and nibbled off by the bacteria. The other is the cortical 
type, in which the pelvis is little involved, at least at first, 
and in which abscesses develop in the parenchyma of upper 
or lower pole. 

From these foci bacteria descend with the urine, and after 
the process has proceeded for some time, they succeed in 
securing a foothold in the bladder mucosa. Buerger has 
diagnosed early renal tuberculosis by finding the organism in 
a bit of edematous mucous membrane snipped from the 
bladder wall just below the ureteral orifice on the infected 
side. Only when the bladder becomes involved does the 
patient awaken to the fact that all is not well with him. 
Renal tuberculosis is nearly always painless. It is the blad- 
der involvement which troubles the patient. Rarely the 
presence of considerable blood in the urine is the first symp- 
tom; as a rule, the history of a case of renal tuberculosis is 
one of slowly increasing bladder irritability. 

If the process continues, the bladder becomes more com- 
pletely involved, the wall thickens, scars distort the interior. 
The affected ureter becomes shorter and dilates; the lower 
end of the other ureter becomes thickened and indurated, and 
the infection spreads, presumably by the lymphatics of the 
ureter, into the second kidney. 

No medicines avail. No case of renal tuberculosis has 



262 AN OUTLINE OF GENITO-URINARY SURGERY 

ever been proved to be cured except by nephrectomy, either 
at the hands of the surgeon or brought about by total de- 
struction and gradual dissolution of the kidney. 

Tuberculosis is never primary in the bladder. The diag- 
nosis of uncomplicated renal tuberculosis is, therefore, within 
the reach of every practitioner. If there are no genital le- 
sions, pus and tubercle bacilli in the urine must come from the 
kidney. As a general rule, the urine in renal tuberculosis 
does not contain other bacteria; if the stained sediment from 
a catheter specimen of urine shows pus and no bacteria, ore 
should suspect tuberculosis, and have the urine inoculated 
in a guinea-pig or examined microscopically. This is done 
nowadays by many laboratories, boards of health, and 
medical schools, so that the physician without laboratory 
facihties need not lack the help which a test of this sort 
will give him. 

The study of the renal condition must be done through cys- 
toscopy. Often anesthesia will be required, and in this event 
spinal anesthesia is admirable. It is often impossible to 
tell, without cystoscopy, which side is affected. The healthy 
kidney hypertrophies; pain may be caused by the stretching 
of its capsule, and the enlargement may be perceptible on 
palpation. Surgeons misled by the pain and enlargement 
have been known to remove the hypertrophied normal kid- 
ney, leaving a kidney normal even to intra-abdominal pal- 
pation, but absolutely destroyed by tuberculosis. 

If one kidney alone proves to be infected, it should be re- 
moved. A careful study by Israel of patients nephrecto- 



GENITO-URINARY TUBERCULOSIS 263 

mized for various causes showed that the prognosis was 
distinctly good; that one of the earliest cases was still alive 
fifteen years after the operation, and had borne several chil- 
dren. Of the cases nephrectomized for tuberculosis in the 
series collected by Cabot and Crabtree, over 50 per cent, 
were permanently improved. 

The operation should be followed for months or even years 
by careful hygiene and injections of tuberculin. Our ex- 
perience at the Massachusetts General Hospital has demon- 
strated the value of these measures. About 25 per cent, of 
all cases develop sinuses in the nephrectomy wound, and the 
healing of these is greatly hastened by proper after-treat- 
ment, i. e., hygiene, direct sunlight, and tuberculin. Nearly 
all of these cases have infected bladders; when the main focus 
of infection, which is the kidney, has been removed, the 
bladder ulcerations get a chance to heal. 

The process of getting well, so far as the bladder is con- 
cerned, is divided into two parts: First of all, the ulcerations 
must heal. This process is aided by the administration of 
sandalwood oil, 10 minims in a capsule, one to be taken dur- 
ing each meal; hexamethylenamin has no curative value in 
tuberculosis and serves simply to irritate the hypersensitive 
bladder. Healing is further aided by the instillation into the 
bladder of some therapeutic agent. In our experience the 
best results have been secured by the use of gomenol oil. 
One ounce is injected into the empty bladder once or, better, 
twice a w^ek. Good results have also been obtained by the 
instillation of increasingly strong solutions of carbolic acid — 



264 AN OUTLINE OF GENITO-URINARY SURGERY 

1 ounce of § per cent, solution is used at first, and is injected 
twice a week. If no reaction is evident, a 1 per cent, carbolic 
acid solution should be used. The strength of the solution 
may be gradually increased to 5 per cent., but should always 
be kept so low that the reaction, which is manifested by 
slight hematuria, does not last for more than twenty-four 
hours. 

After the ulcers are healed the bladder will frequently be 
found to be contracted by scar tissue. The gradual dilata- 
tion of the bladder forms the second stage in the treatment of 
tuberculous cystitis. About twice a week it should be filled 
with fluid until the patient complains of the distention. The 
capacity should increase | ounce at a time. For distending 
the bladder a very weak solution of corrosive sublimate 
(1 : 20,000 to 1 : 10,000) may be employed. The mercuric 
chlorid influences favorably whatever remains of the tuber- 
culous ulcerations. 

The presence of other foci of tuberculosis need not neces- 
sarily contraindicate operation. Frequently other lesions 
improve after nephrectomy when the toxemia from the renal 
process is removed. The possibility of stirring up a latent 
pulmonary infection is best prevented by the use of gas- 
oxygen as an anesthetic. 

If the disease should prove to be bilateral when first seen 
by the cystoscopist, the prognosis is poor. The disease may 
have remissions, but will within a few years reduce the 
amount of kidney tissue to a point where it is insufficient to 
support life, One is surprised at the degree to which this 



GENITO-URINARY TUBERCULOSIS 265 

process of kidney attrition may be carried. One-fourth of 
the normal amount of kidney tissue will support Hfe very 
well, and if the process of destruction is slow, life may be 
maintained with considerably less tissue than that in com- 
mission. 

The worst aspect of bilateral renal tuberculosis from the 
patient's point of view is the vesical condition. Frequency 
becomes so great that after a time incontinence results, the 
urine dribbling from the bladder, the capacity of which is only 
an ounce or two. When this stage is reached the patient 
suffers less pain, and is troubled mainly by the discomfort of 
a rubber urinal. 

Operations for diverting the urinary stream from the blad- 
der, such as ureterostomy, have been advocated by Rovsing, 
but their value is questionable. Cystostomy gives relief 
from pain, but is a disagreeable feature in itself. The best 
of antituberculosis hygiene, the use of sandalwood oil, and 
instillation of gomenol oil are the chief measures to be em- 
ployed in a case of bilateral renal tuberculosis. 

Genital tuberculosis in the male is almost always primary 
in the epididymis. KoU and Cunningham have each reported 
2 cases of primary prostatic tuberculosis, but the condition 
is rare. Tuberculous epididymitis begins insidiously; often 
it is noticed for the first time when a blow upon the testicle 
has attracted the patient's attention to that part. 

Tuberculous Epididymitis Following an Injury. — H. S. N., teamster, 
age forty-one, married. Entered the hospital November 20, 1916. 
Past history unimportant, except for an attack of gonorrhea at the age of 
twenty, apparently of short duration. 



266 AN OUTLINE OF GENITO-URINARY SURGERY 

Two months ago, while getting out of a truck, he slipped and the side 
of the truck struck him in the groin. He had severe pain in the right 
testicle for half an hour, but no swelling at that time. Three or four 
weeks later,- however, testicle began to swell. The swelling was accom- 
panied by a drawing sensation, but by no real pain in testis. Micturition 
normal. Patient has no children; wife has had three miscarriages. Sex 
function normal. 

Physical examination shows a healthy appearing man. Penis and 
left testis normal. Hydrocele on right. This was tapped and I5 ounces 
of hazy fluid withdrawn. Upper pole of epididymis very much swollen, 
hard, and nodular. Suggestive of tuberculosis. Vas not enlarged. 
Prostate soft. Right vesicle apparently a little swollen and hard. 
Urine clear and clean; no albumin. 

On November 27, 1916, an epididymovasectomy was done under local 
anesthesia. Epididymis found thickened at upper pole, the induration 
extending on to cord. Testis normal. Examination of cut sections of 
epididymis showed areas of normal tubules, some filled with broken- 
down cells and leukocytes. Adjacent areas showed necrosis, lymphoid 
infiltration, and some epithelial cells. 

Patient made an excellent recovery and left hospital in six days. 
Examination, December 19, 1916, showed a very good result. Testis 
normal. No thickening in scrotum. Urine clear and clean; no albumin 
by heat,. 

In the preceding case acute tuberculous epididymitis ap- 
parently did follow injury. There is a possibility that the 
epididymis may be so prepared for the reception of wander- 
ing bacilli. Belfield has shown that the epididymis has an 
excretory function, a legacy from its origin in the wolfl&an 
body, and it has been generally beUeved that this is the reason 
why tuberculosis aiBfects the epididymis and not the testicle. 
The testicle shows an amazing resistance to infection, even 
when the process in the epididymis is extensive enough to 
form sinuses. 

In early tuberculous invasion of the epididymis we ^nd a 
hard, smooth enlargement of one or both poles of the epididy- 



GENITO-URINARY TUBERCULOSIS 267 

mis not vastly different from the enlargement which occurs in 
the subsiding stage of acute gonorrheal epididymitis. 

The testis and epididymis are easily differentiated. The 
vas is thickened, especially at its lower end, and has a beaded 
feeling. Sometimes the outlines of the scrotal contents are 
obscured by the presence of fluid; this must be withdrawn 
before satisfactory palpation can be done. As a rule, the 
seminal vesicle upon the affected side is harder and thicker 
than its fellow. 

If left alone, the process in the epididymis may form an 
abscess, which in time becomes a sinus; sometimes spon- 
taneous healing takes place after the discharge of all the in- 
fected tissue through the sinus. This process occupies months 
or years; meanwhile the disease may extend to the other 
.epididymis. 

A tuberculous epididymis should be removed shortly after 
the diagnosis is made. The operation can be done under 
local anesthesia; the epididymis is dissected off the testis 
and removed. The vas is freed from the cord, the lower 
end is grasped in a curved hemostat and carried as high as 
possible in the inguinal canal. The skin is incised over the 
point of the hemostat, the vas is drawn up, and as much as 
possible is removed through the small incision in the groin. 
The testis, cleaned of tuberculous adhesions and inflamma- 
tory masses, is replaced in the scrotum. Only very rarely 
does a testicle so treated require further operation. 

The infection may extend from seminal vesicle into pros- 
tate and involve the mucous membrane overlying that gland. 



268 AN OUTLINE OF GENlTO-URlNARY SURGERY 

This gives a picture similar to that of renal tuberculosis, 
namely, bladder irritabihty, ulceration of bladder neck, 
pyuria. To prove that the kidneys are not imphcated is 
rather a difficult matter. The introduction of a cystoscope 
through a prostate so infected is not to be undertaken lightly. 
Under the circumstances normal kidney function is perhaps 
the best evidence obtainable that there is no serious renal in- 
volvement. The case should, after epididymectomy, be 
treated with sandalwood oil, tuberculin, and gomenol, and 
every few months the renal condition should be carefully 
checked up. The prognosis in tuberculous prostatitis is not 
bad; both epididymes may have to be removed, and the 
prostate gland may have to undergo destruction by the 
tubercle bacillus, but in time the infection should die out. 

Radical removal of prostate and seminal vesicles has been 
practised, but seems rather an unsafe procedure. The open- 
ing up of tissues so rich in blood- and lymph-channels to the 
tuberculous pus appears to us rather risky. The chance of 
getting a tuberculous urinary fistula through the perineum is 
large. On the whole, conservative treatment of prostatic 
tuberculosis seems preferable in the large majority of cases. 

Not infrequently one or the other kidney proves to be in- 
fected. The infection is usually established by the time the 
doctor sees the patient, so that it is difficult to be sure whether 
the renal or the epididymal infection was the first to appear. 
There is considerable evidence to show that infection of a 
seminal vesicle may ascend to the corresponding kidney. 
Whatever route the infection takes, the infected organ should 



GENITO-URINARY TUBERCULOSIS 



269 



be removed. Nephrectomy and bilateral epididymectomy, 
done simultaneously or a few months apart, have been quite 
constantly associated in our series of genito-urinary tuber- 
culosis, and recovery from the infection has been the reward in 
a considerable number of such cases. 




Fig. 71. — Tuberculous kidney remov^ed at operation. History of 
pain in region of this kidney for four years. Bladder symptoms for past 
eighteen months. (See case report H. S.) 



Genito-urinary Tuberculosis — Nephrectomy and Epididymectomy. — 

H. S., a farmer, age thirty, single. Entered the hospital January 12, 1918. 
Family history and past history negative. About four years ago began 



270 AN OUTLINE OF GENITO-URINARY SURGERY 

to have attacks of severe pain in right flank, on one occasion requiring 
morphin. These attacks stopped for awhile, but came on again about 
three years ago. Then he began to be troubled with frequency. At 
times his urine contained blood. Lately he has had very little pain in 
right kidney, but bladder causes him a great deal of trouble. Frequency 
during the day every two hours or less; at night every fifteen minutes to 
one hour. Vibration causes pain in bladder. General health good. No 
particular loss of weight. Lost left testicle from unknown cause in early 
childhood. 

Physical examination shows a well-developed and nourished man. 
Heart and lungs normal. Kidneys not palpable. Reflexes normal. 
Abdominal examination negative. Epididymis thick and hard, not very 
much so, but still definitely abnormal. Vas not enlarged. Urine 
cloudy; one large chunk of detritus or slough; albumin trace; sugar 0. 
Sediment (stained specimen), pus; a few bacilli and cocci. Cystoscopy: 
Bladder holds 2^ ounces. Typically tuberculous. Left ureter retracted, 
but orifice appears normal. Catheterized easily; clear urine obtained. 
Sediment shows rare blood-cell and epithelium. No pus. Phthalein: 
Appearance time four minutes, good output. Right ureter a gaping hole. 
Catheterized for 6 cm. Backflow from bladder. Bladder specimen 
searched for tubercle bacilli. Some acid-fast organisms found. 

January 17, 1918, right nephrectomy. Ureter found thickened. 
Kidney (after removal and splitting) shows typical cavities at upper and 
lower poles (Fig. 71). Right epididymectomy and vasectomy. Epidid- 
ymis practically a cavity of thick pus. 

Catheter left in bladder and bladder irrigated with 5 per cent, carbolic. 
Some breaking down of kidney wound superficially. The bladder was 
irrigated the third and fifth day after operation with carbolic (2 and 3 per 
cent.). Some improvement noted after catheter was removed. 

To recapitulate: Genito-urinary tuberculosis may be 
primary in kidney or epididymis. Not infrequently it ap- 
pears more or less simultaneously in both. Foci which can 
be removed without undue risk should be so treated as they 
develop, provided always that one sound kidney exists. 
Meanwhile the resistance of the organism to the bacillus is 
increased by proper living and by the injection of tuberculin. 

The mutilation does not seriously handicap the individual. 



GENITO-URINARY TUBERCULOSIS 27 1 

One kidney suffices. He will probably be sterile whether 
epididymectomy is done or not, as the exudate .plugs the 
channels of semination. If properly treated he should re- 
tain his testicles, as orchidectomy is necessary only in a very 
small percentage of cases. 

Barney, J. D.: The Ultimate Results of Genital Tuberculosis in the 
Male, Jour. Amer. Med. Assoc, 1914, kiii, 2274-2276. 

Cabot, H., and Barney, J. D.: Operative Treatment of Genital Tuber- 
culosis. Indications and Technic, Jour. Amer. Med. Assoc, 1913, 
bd, 2056-2058. 

Dock, G., Young, E. L., Jr., Lower, W. E., Shupe, T. P., and Kretsch- 
MER, H. L.: Symposium on Tuberculosis of the Kidney, Trans. 
Amer. Urolog. Assoc, 1916, x, 199-261. 

Lo^vER, W. E., and Shupe, T. P. : End-results of Nephrectomy for Renal 
Tuberculosis, Surg., Gynec, and Obst., 1917, xxv, 522-525. 

Lyons, O. : Tuberculosis of the Genital Organs in Children, Jour. Amer. 
Med. Assoc, 1913, bd, 2051-2054. 



CHAPTER XV 

GONOCOCCUS INFECTION IN THE FEMALE 

Vulvovaginitis of Little Girls. — The mucous membrane of 
the vagina of female children must be peculiarly susceptible 
to the gonococcus, judging from the ease with which this 
organism is transmitted. Among the children of well-to-do 
parents the disease is rare, although it may appear most un- 
expectedly. Under such circumstances the infection is 
probably transmitted by the nurse, or by someone, herself 
infected, who takes partial care of the child. In poor fam- 
ilies, where living conditions are bad, the disease is often 
caught by the child's sleeping with an older girl who has 
gonorrhea. Direct infection undoubtedly does occur, either 
through intercourse with small boys or by contact with an 
older person. Epidemics of gonococcus vulvovaginitis in 
institutions are well recognized, and are due to dissemination 
of the infection through the medium of infected hands, in- 
fected towels or diapers, or infected bath-tubs. 

The infection usually has an acute onset. Dammed back 
by the hymen, the discharge keeps the vaginal mucosa soaked 
with infectious material. The surplus discharge pours out 
from the vagina, and if ulcerative processes exist, it is streaked 
with blood. 
272 



GONOCOCCUS INFECTION IN THE FEMALE 273 

In the chronic stage the introitus is reddened and the 
clothes are stained by the thin, yellowish discharge; unless 
vigorously treated this condition exists for years. Rarely 
the infection may invade the fallopian tubes, and give the 
symptoms of acute salpingitis. 

The diagnosis depends upon finding the biscuit-shaped 
Gram-negative diplococcus in pus-cells. In acute cases the 
gonococcus should be numerous and in almost pure culture. 
In cases of more than several weeks' standing the discharge 
may contain so many other bacteria that the gonococcus is 
difficult to find. The question has been raised whether the 
Gram-negative diplococci found in children who have but 
little discharge is really the gonococcus. It is true that there 
occur in little girls infections of the vagina which are not 
due to the diplococcus of Neisser. In our opinion the com- 
bination of purulent vaginal discharge and intracellular 
Gram-negative diplococci of typical morphology and ar- 
rangement means gonorrhea. In cases in which, when seen 
for the first time, the discharge is thin and scanty, the diag- 
nosis is more difficult. The gonococcus, if it was the original 
infecting agent, is likely to be scarce. Such cases one should 
hesitate to diagnose as gonorrheal, particularly if there is no 
history of profuse purulent secretion, and no evident source 
of contamination. 

The smear is best made by wrapping cotton about the tip 
of a probe, passing it into the depths of the vagina, and twist- 
ing it around. If the endoscope can be used, the smear 

should be taken through that. 
18 



274 AN OUTLINE OF GENITO-URINARY SURGERY 

The treatment in the acute stage must be soothing and 
cleansing. At first these children resist. If handled gently 
but firmly they quickly learn to behave and to allow the 
mother to give the treatments. In the very acute stage the 
flushing out of the vagina with 5 per cent, argyrol injected 
with a rubber ear syringe should be done three times a day. 
After each instillation a pledget of cotton, which quickly be- 
comes soaked with the argyrol, is placed between the labia 
and the child is kept lying down for ten to fifteen minutes. 
After a week or so the instillation of argyrol should be pre- 
ceded, at least once a day, preferably twice, by irrigation with 
a quart of warm potassium permanganate solution, about 
1 : 6000 in strength. This is best given through a soft- 
rubber catheter inserted into the depths of the vagina; after 
the potassium permanganate has run out of the vagink the 
argyrol should be injected. A 10 per cent, solution may now 
be used. 

This treatment must be kept up faithfully until no more 
discharge is seen. The argyrol may then be omitted and a 
daily douche of silver nitrate — 1 : 6000 — substituted. In 
some cases this will resurrect the discharge, and should be 
given up for the potassium permanganate douche. When the 
process appears to be cured, all treatment should be stopped 
and the child seen once a week for a month, and once a month 
for three months after that. At every visit smears made by 
introducing a dry cotton-tipped applicator into the depths of 
the vagina, there twisting it around, and then wiping it on a 
glass shde, should be examined for the presence of pus-cells, 



GONOCOCCUS INFECTION IN THE FEMALE 275 

Pus-cells mean infection, and if they are present, the treat- 
ment should again be started. The cervix, even in very young 
girls, has been shown to be a stronghold of the gonococcus. 
In chronic cases the application of 10 per cent, silver nitrate 
to the walls of the vagina and to the cervix should be made 
through an electrically lighted straight urethroscope or en- 
doscope. 

The urethra must not be overlooked, as a urethritis may 
be the focus from which infection recurs. For that, urethral 
instillations of argyrol are given with a medicine-dropper. 
In my experience the accessory glands in girls under twelve 
are never infected. 

If the above treatm^ent is conscientiously followed cure can 
be achieved in the great majority of cases. Occasionally a 
very obstinate case seems to resist all efforts. Cultures of 
the vaginal secretion may show a predominance of some par- 
ticular organism, and vaccine from that or from the gono- 
coccus may be tried. The direct application of silver, how- 
ever, seems to be the best single remedy for such cases. 

One meets not infrequently the statement that vulvovag- 
initis in Httle girls is incurable, hence should be left alone. 
The same advice as to treatment is given by those who say 
that the infection will not persist beyond puberty. 

With both these opinions we heartily disagree. Our ex- 
perience at the Massachusetts General Hospital has shown 
that a proved cure may be expected in considerably over half 
of the patients treated, even when treatment is largely de- 
pendent upon the mother's co-operation. Probable cure, 



276 AN OUTLINE OF GENITO-URINARY SURGERY 

with the disappearance of the gonococcus, can be obtained in 
practically all cases who will submit to the lengthy and tire- 
some measures which may be needed. 

In the adult the gonococcus may invade the urethra, the 
glands of Skene and Bartholini, the glands lining the cervical 
canal, and the fallopian tubes. These are the points upon 
which treatment should be concentrated. In the acute cases 
douches twice a day of hot potassium permanganate (1 : 3000), 
the introduction of argyrol suppositories into the vagina, and 
the ingestion of capsules of sandalwood oil will quiet the in- 
fection. Local treatment consists of the instillation of argyrol 
(5 to 10 per cent.) into the urethra, the application to the 
cervical canal of tincture of iodin, silver nitrate (10 per cent.), 
or crude carbolic acid. 

If the infection persists in the cervical glands, the ap- 
plication of the actual cautery to the walls of the cervical 
canal may be resorted to. Gonococci perish at 119° F. 
This degree of heat can be reached without seriously injuring 
the tissues of this region. 

If Skene's glands are involved, they must be injected with 
silver nitrate (1 per cent.) through a blunt-pointed needle 
and h3T>odermic syringe. If Bartholini's glands become in- 
fected, excision is the only cure. Otherwise the infection 
persists for years, not infrequently forming abscesses from 
time to time, and, at any rate, remaining a focus of reinfec- 
tion. 

Infection of the fallopian tubes must be treated sympto- 
matically. For acute infection, rest in bed and hot douches 



GONOCOCCUS INFECTION IN THE FEMALE 277 

twice daily should be tried. As a rule, the process will sub- 
side. If the signs of tubal inflammation entirely disappear, 
well and good. If the tube continues to be a thickened, in- 
fectious structure, keeping up a vaginal discharge or caus- 
ing pelvic symptoms, salpingectomy should be considered. 
The more severe cases of pelvic infection must be seen by the 
surgeon, and, if pelvic peritonitis exists, the abdomen should 
be opened and the focus removed. 

Johnson, W. S.: The Diagnosis of Latent Gonorrhea in the Female, 

Calif. State Jour. Med., September, 1912. 
Smith, G. G.: The Treatment of Gonococcus VuK^ovaginitis, Amer. 

Jour. Dis. Children, 1914, vii, 230-237. 



CHAPTER XVI 

IMPOTENCE AND STERILITY 

Disorders of the sexual function in men deserve a book by 
themselves. Many pages could be filled with a description 
of their various manifestations and the reasons for their exist- 
ence. The usual signs of loss of sexual power have to do with 
erection and ejaculation. Erection may be absent or ill- 
sustained. Ejaculation may be premature — that is, occur- 
ring before intromission or immediately thereupon. Second- 
ary symptoms of sexual derangement include perineal or 
testicular ache following intercourse, backache, occipital 
headache, and generally "caved-in" feeling. According to 
Townsend and Valentine, impotence or sexual disorders are 
present in 6.5 per cent, of all genito-urinary cases. 

''Sexual neurasthenics," so called, may be divided into two 
classes. The symptoms of Class One are due to psychic 
or purely functional causes. Examples of this type are the 
youth who fears to get married because he has masturbated 
in the past, and now, after long unsatisfied sexual excite- 
ment, because he finds a gluey urethral discharge, he believes 
he has "lost his manhood"; the man who has practised coitus 
interruptus until the sexual act is followed by prostatic pain 
and a feeling of exhaustion; the sexualist, who, after long- 
278 



IMPOTENCE AND STERILITY 279 

continued excessive indulgence, finds his powers growing less. 
In such cases regulation of sexual hygiene will effect a cure. 

Class Two consists of those whose sexual symptoms are 
due to an actual, demonstrable pathologic condition. The 
hne between these two classes is somewhat indefinite; the 
status of borderline cases must be determined by thera- 
peutic test. If, following a correction of faulty habits alone, 
the s}Tnptoms are relieved, the case may fairly be put in 
Class One. There are others who show no definite abnormal- 
ities, who nevertheless do not respond to hygienic measures 
alone, but who require local treatment for relief of their 
symptoms. It is probable that every case of this sort shows 
some departure from the normal — undue redness of the veru- 
montanum or a streaked appearance in the posterior urethra. 
If no definite pathology, such, for example, as infection of 
prostate or vesicles or papilloma of the posterior urethra, can 
be demonstrated, these cases should be classified with the 
functional disorders. 

A considerable majority of all cases of sexual disorders 
take origin in physical abnormalities. Townsend and Valen- 
tine, from a study of 111 cases, conclude that 64 per cent, of 
sexual disorders are due to or originate in peripheral nerve 
irritation emanating from the posterior urethra or the col- 
liculus seminalis. They found pathologic processes in the 
prostate in 86, in the seminal vesicles in 45, in the colliculus 
in 11, lithemia in 15, diabetes in 3, intestinal auto-intoxication 
in 4, disturbances of the kidney in 27. 

The treatment of those cases whose symptoms are due to 



28o AN OUTLINE OF GENITO-URINARY SURGERY 

psychic or functional causes consists, first of all, in getting 
the patient's point of view. The facts will probably have 
to be drawn out by sympathetic cross-questioning; during 
this process the physician should find out how much the 
patient knows about sexual matters, and how large a part of 
his trouble is due to ignorance or to psychologic factors. 
His fears may be founded upon perfectly natural phenomena. 
For example, many of my patients have mentioned as a sign 
of trouble the glycerin-like discharge which is the natural con- 
comitant of long-continued sexual excitement. Some indi- 
viduals cannot become aroused sexually unless the woman is 
of a certain type. The sexual libido is a queer appetite, 
capricious in some, in others omnivorous. 

After hearing the patient out, one should examine his 
reflexes and external genitals, and should determine by rectal 
palpation the condition of the prostate and vesicles. This 
should be done in every case, even when no lesion is sus- 
pected. It goes far toward establishing the patient's confi- 
dence by giving the doctor's opinion a basis in fact. The 
urine should be examined for sugar; impotence is frequent in 
diabetics, and disappears when the urine becomes sugar free. 

If no physical cause is found to account for the patient's 
symptoms, he should be given a simple talk on sex physiology 
and set straight in his sexual hygiene. If these measures 
seem inadequate, a more thorough search for physical causes 
must be made. The secretion of the prostate and vesicles is 
examined for signs of inflammation. Possibly posterior 
urethroscopy should be done. It has been my experience 



IMPOTENCE AND STERILITY 281 

never to have found, by urethroscopy, lesions which would 
not have been taken care of by the ordinary methods of 
treatment, such as dilatation, instillation of silver nitrate, 
and massage. Observers of much greater experience report 
various pathologic processes and advise correspondingly 
complex measures for their cure. It is my belief that at least 
99 per cent, of all cases respond in a satisfactory manner to 
the simpler therapeutic measures. 

The posterior urethra may show areas of congestion or 
granulation, perhaps bullous edema or cysts. The verumon- 
tanum is likely to be deeply suffused. These lesions, how- 
ever, are usually the result of an underlying infection, and 
treatment of them, while it may temporarily reUeve, will not 
eradicate the source of the trouble. 

Even if no abnormalities are discovered, the sexual neuras- 
thenic will be greatly benefited by dilatation of the posterior 
urethra with sounds or Kollmann dilator, instillations of 1 c.c. 
of 10 per cent, silver nitrate into the posterior urethra, and 
by gentle massage. Treatment should be given once a week. 

If there is found to be urethritis or infection of the pros- 
tate or vesicles, some one of these three measures, or a com- 
bination of them all, must be reUed upon to clear up both the 
actual lesion and the symptoms resulting therefrom. 

Impotence Due to Seminal Vesiculitis. — J. A. B. was an example of 
this. He was a postal clerk, age thirty-eight, married, six children. He 
came for ad\-ice partly because of loss of sexual \igor, accompanied by 
emissions, partly because he had been told he had Bright 's disease. He 
had never had any venereal disease or any serious illness. For the pre- 
ceding year he had had dull pain in both flanks, and had noticed a change 
in his sexual powers. 



282 AN OUTLINE OF GENITO-URINARY SURGERY 

Physical examination of chest and abdomen was negative. SystoHc 
blood-pressure 158. External genitalia were normal. No stricture. 
Right lobe of prostate and seminal vesicle were matted together and gave 
a feeling of soft distention. Secretion on massage showed a large amount 
of pus. Urine: Clear with a few shreds; specific gravity 1012; albumin 
slightest trace; sugar 0. Sediment: A few leukocytes and epithelial cells; 
no casts. Cystoscopy showed a normal bladder, save for some redness of 
trigone. Prostatic middle lobe shows some enlargement. Both ureters 
appear normal and emit clear jets. aj-Ray showed no stones. 

He was treated for two or three months by dilatation of the posterior 
urethra with the Kollmann dilator, silver nitrate irrigations, and massage. 
As the condition of his vesicles improved, as judged by the evidence of 
the palpating finger, his sexual powers increased and his pain diminished. 
When last seen he had no complaint as regards his sexual function. The 
vesicles were much softer and the exudate nearly absorbed. His back- 
ache continued, and was said by an orthopedist to be caused by pronation 
of feet. 

In the management of these cases the general condition of 
the patient must be considered. Change of scene, recrea- 
tion, open air, will often do much more than local treatment. 
Sexual intercourse must be stopped during active treatment 
and alcohol is forbidden. 

Sterility. — The problem of sterility is, as a rule, entirely 
separate from that of impotence. The woman's failure to 
conceive may be the result of abnormalities of the female 
organs of generation, or may be due to the husband's inabil- 
ity to impregnate. Rarely the difficulty resides in the reac- 
tion between the male and female secretions, either indi- 
vidual, with a different partner, being fertile. It goes 
without saying that a union in which the semen cannot be 
deposited in the vagina will be sterile. Obstacles to copula- 
tion are: in the female, excessive obesity, absence of vagina, 
imperforate hymen, and vaginismus; in the male, impotence, 



IMPOTENCE AND STERILITY 283 

well-marked epispadias or hypospadias, exstrophy of the 
bladder. 

Granting for the moment that the husband is normal, there 
are various conditions in the wife which prevent conception.^ 
These may be divided into congenital abnormalities, acquired 
abnormalities, results of inflammation, and functional dis- 
ability. 

Congenital abnormalities include absence or atresia of the 
vagina, double or septate vagina, smallness of the cervical 
orifice, infantile uterus (frequently accompanied by under- 
development of the ovaries). 

Acquired abnormalities of non-inflammatory nature which 
may prevent conception are uterine polyp, fibroid tumors of 
the uterus, and ovarian and parovarian cysts. Lacerations 
of perineum and of cervix and retroversion are not considered 
by Kelly to be frequent causes of sterility. 

Inflammatory conditions which are hostile to and perhaps 
prohibitive of conception are caused to a very great extent 
by the gonococcus. The change in reaction from alkaline 
to acid which the products of infection may bring about in 
the cervical secretion is hostile to the spermatozoa. The 
formation of abnormally thick, viscid secretion may prevent 
their passage through the cervical canal. Infection of the 
tubes is a frequent cause of infertility. During the stage of 
pus formation the spermatozoa are likely to be killed by the 
acid, enzymotic secretion; later the lumen of the tube may 

1 For an excellent presentation of this aspect of the question, see Kelly, 
"Medical Gynecology," 1909, pp. 339-356. 



284 AN OUTLINE OF GENITO-URINARY SURGERY 

be strict ured and impervious. Tuberculous salpingitis was 
found by Sanger to be the cause of sterility in 1 out of 397 
childless marriages. 

The functional causes of sterility are less definite and are 
more difficult of diagnosis. Excessive obesity, probably 
through alterations in the secretions of the thyroid, adrenals, 
and ovaries, is considered by Kelly to be a possible cause. 
Alcoholism and morphinism affect the sexu^ial cycle in women. 
Acute infectious diseases may cause atrophy of the ovaries, 
just as mumps may cause atrophy of the testicle in man. 
Unless some definite abnormality is suggested by the history 
or the physical examination, one is not justified in attribut- 
ing sterihty to the condition of the ovary until every other 
possible cause has been excluded. 

On the masculine side, sterility may be due to factors, 
mentioned above, which prevent the deposition of semen 
within the vagina. Stricture of the urethra and polyp of the 
posterior urethra may prevent the discharge of the seminal 
fluid in sufficient quantities to impregnate. Occlusion of 
the ejaculatory ducts gives rise to the condition known as 
"aspermia." 

As regards the semen itself, it may contain no spermatozoa 
(azoospermia), or only a few (oligospermia), or those which 
are present may be dead or lacking in vitality (necrospermia). 
The cause of azoospermia and oligospermia may reside in the 
testicle itself. Certain diseases of the testis, such as the or- 
chitis of mumps and perhaps that of typhoid fever, result 
in atrophy of the spermatogenetic cells. Cryptorchidism, 



IMPOTENCE AND STERILITY 285 

as a rule, does the same thing, although cases have been 
reported in which normal spermatozoa were secreted by 
undescended testes. Excessive obesity has been mentioned 
as being a possible cause of azoospermia, and sexual excess 
will, temporarily at least, cause a disappearance of sper- 
matozoa from the semen. Occlusion of the vas or of the 
epididymal tube will, of course, prevent the passage of 
spermatozoa. If the process is bilateral, steriHty results. 
This is seen in tuberculous epididymitis, sometimes when only 
one epididymis is involved. It is then probably due to the 
invasion of both seminal vesicles by the process. Gonorrheal 
epididymitis is a frequent cause of sterility. Out of 242 cases 
of double epididymitis. Finger found 207 cases of azoospermia. 

Inflanomatory processes in the seminal vesicles may block 
the outlets. A much more usual effect, however, is the pro- 
duction of necrospermia. The spermatozoa are weakened or 
killed by the acid products of suppuration. Although the 
gonococcus is responsible for the vast majority of such cases, 
it must be borne in mind that infection by other organisms 
may occur in men who have never had gonorrhea. 

Brief reflection upon the foregoing facts will speedily 
bring one to the conclusion that the gonococcus is responsible 
for sterility in a large percentage of all cases. From a study 
of sterility statistics in both men and w^omen it would seem 
that at least half of the cases might be attributed to this etio- 
logic factor. Another fact which impresses itself upon one 
is the large number of cases in which responsibility for an 
unfruitful union rests with the man. Sanger, in analyzing 



286 AN OUTLINE OF GENITO-URINARY SURGERY 

110 childless marriages, found that in 45.4 per cent, the hus- 
band's spermatozoa were absent or greatly reduced in num- 
ber. Kehrer, in a series of 96 such marriages, found the hus- 
band sterile in 36 per cent. Gross, in 192 cases, blamed the 
man in 18 per cent. More figures could be set forth; these 
are enough to prove that in every case of sterility the condi- 
tion of the husband as well as that of the wife should be thor- 
oughly investigated. 

The study of such a case requires first a careful history of 
the sexual life of both individuals. The wife should be- ex- 
amined for gross abnormalities of the generative organs. 
The semen of the husband should then be examined. After 
at least a week of continence his discharge should be col- 
lected in a condom, which should be suspended in a wide- 
mouthed bottle of tepid water and brought at once for in- 
spection. The quantity and reaction of the seminal fluid 
should be noted. The normal reaction is alkaline to litmus; 
acidity is the result of inflammation of the vesicles. A few 
drops are placed upon a warm shde and examined under the 
high dry power of the miscroscope. In normal semen the 
number of spermatozoa is tremendous. Lode estimated that 
there were 200,000,000 in one ejaculation. Yet of these 
comparatively few reach the cervical canal. The reaction of 
the vaginal secretion is normally faintly acid, and is not con- 
ducive to long life on the part of the spermatozoa. It is 
easy to see, therefore, that with semen containing only a few 
spermatozoa the chances of impregnation are very poor. 
The spermatozoa should be uniform in size and shape, and a 



EMPOTENCE AND STERILITY 287 

fair proportion of them should be vigorously motile even after 
several hours. Reynolds divides the life of a spermatozoon 
after ejaculationinto three periods: (1) The ''progressive 
vibratile," characterized by a violent side-to-side lashing of 
the tail which drives the spe m straight ahead, always against 
the current. (2) The "undulatory tactile," in which the tail 
makes long, slow sweeps and the head weaves from side to 
side. During this phase the spermatozoon seems to nose its 
way among the cells and debris of the secretion. (3) The 
''stationary bunting," during which the sperm endeavors to 
force its way into the cell with which it is in contact. Of 
these three phases, the last is never seen under artificial 
conditions. Persistence of the first stage is an indication of. 
strong vitaUty; in weak specimens the second stage appears 
early. 

If healthy spermatozoa do not appear in a specimen of 
semen, the observation should be repeated at least three 
times. If the semen is always abnormal, the cause for this 
abnormahty must be sought. Azoospermia suggests bilat- 
eral disease of the testicles or blockage of the seminal canal. 
Oligo- or necrospermia suggests inflammatory disease of the 
seminal vesicles. If the patient has had bilateral epididy- 
mitis, and now has no spermatozoa in his semen, the opera- 
tion of vaso-epididymostomy, devised by Martin, may be 
done. This consists of anastomosing the vas deferens, which 
must be proved to be patent below the point of anastomosis, 
to the upper pole of the epididymis. In doing this operation 
upon 18 patients Wolbarst met with definite success in but 1. 



288 AN OUTLINE OF GENITO-URINARY SURGERY 

Martin reported 7 cases. In 4 spermatozoa appeared in the 
semen, 2 were not traced, and 1 was a failure. Lespinasse 
has modified Martin's operation, and reports success in 10 
out of 11 operations performed on dogs. 

For the condition of oligo- or necrospermia caused by in- 
flammation of the vesicles a long course of massage and dila- 
tation must be undertaken in the hope that the exudate will 
absorb and the infection die out or become avirulent. Pos- 
sibly drainage of the vesicles might be valuable. 

If the semen obtained by condom is normal, and the wife 
shows no gross abnormalities, specimens of cervical secre- 
tion should be obtained at varying periods after coitus in 
order that the effect of the cervical secretion upon the sper- 
matozoa may be studied. Death of the male element when 
mixed with cervical secretion may be due to the products of 
infection, or to intolerance of the blood-serum of the woman 
for the spermatozoa of the man. If to the former, treatment 
must be given for eradication of the infection. If an unusually 
acid reaction exists in the vaginal secretion, douches of so- 
dium bicarbonate taken just before coitus may be advised. 

This is about as far in the treatment of sterility as the 
physician who has not specialized in this subject can go. 

Further measures consist in securing specimens of uterine 
secretion from the fundus in order to determine their effect 
upon the sperm. If they are not incompatible, and the 
cervical secretion is hostile, artificial impregnation may be 
tried, a few drops of semen being injected into the cavity of 
the uterus. This procedure may also be tried when the man, 



IMPOTENCE AND STERILITY 289 

because of some deformity, such as hypospadias, is unable to 
deposit semen within the vagina. 

The value of glandular therapy in certain cases of sterility 
has not been thoroughly worked out. Cases have been re- 
ported in which conception has followed the administration 
of glandular extract, directed toward stimulation sometimes 
of the ovaries, sometimes of the testes, depending upon 
w^hether the male or the female is at fault. This should be 
tried only when all anatomic lesions are ruled out. 

There are many cases of steriUty in which the cause is 
easy to determine. There are others which baffle even those 
who have gone most deeply into this fascinating study. 
Much progress has been made in recent years, and, as interest 
in the problem grows, more can be expected. One lesson at 
least should be thoroughly learned. That is, that operative 
measures upon the wife for the relief of sterility should never 
be undertaken until the fact of the husband's fertihty has 
been thoroughly established. 

Barney, J. D.: Observations on Sterility in the Male, Boston Med. and 

Surg. Jour., 1914, clxx, 943-947. 
KoLL, I. S.: Etiology, Patliolog>', and Treatment of Sexual Impotence, 

Urologic and Cutaneous Rev., 1915, xix, 541-544. 
Lespin.\sse, V. D.: Obstructive Sterility in the Male. Treatment by 

Direct Vaso-epididymostomy, Jour. Amer. Med. Assoc, 1918, Ixx, 

448^50. 
Reynolds, E.: Fertility and Sterility, Jour. Amer. Med. Assoc, 1916, 

lx\-ii, 1193. 
TowNSEND, T. M., and Valentin-e, J. J.: Functional Sexual Disorders 

Proceeding from the Genito-urinar>' Tract, Med. Record, IMay 27, 

1911. 
WoLBARST, A. L,: Surgical Aspects of IMale Sterility, New York Med. 

Jour., May 19 and 26, 1917. 
19 



INDEX 



Abdominal tumor associated with 
hematuria, 224 
of renal origin, 220 
of splenic origin, 223 
Aberrant vessels in hydronephrosis, 

243 
Abnormalities of spermatozoa, 284 

of urine in renal disease, 216 
Abortion of gonorrhea, 74 
Abscess of prostate, 108 
of testicle, 181 

perineal, from seminal vesicle, 
110 
Acid, boric, in bladder lavage, 19 
Acute cystitis, 191 

hematogenous kidney, 234 
Adenitis, inguinal, 61 
Adenomatous prostate, 124 
Albumin, tests for, 40 
Alexander bandage, 171 
Alkaline cystitis, 195 
Anatomy of seminal vesicles, 109 
Anesthesia in cystoscopy, 28, 262 
in prostatectomy, 147 
local, for circumcision, 67 
for cystotomy, 138 
for operations on scrotum, 168 
spinal, in cystoscopy-, 29 
in perineal section, 102 
technic, 147 
Antiseptics, urinar\% action of, 33 
administration before instru- 
mentation, 20 



ArgjTol in urethritis, 79, 276 

in \-ulvo vaginitis, 274 
Arthritis, gonococcus, 111 

vaccines in, 112 
Asepsis in urethral instrumentation, 

20 

Bacillus acidophilus in alkahne 
cystitis, 95 
colon, epididj-mitis due to, 185 

infection of kidney, 234 
Ducrey's, 61 

tubercle, detection by inocula- 
tion of guinea-pig, 41 
in urine, 41 
Bacteria in urinar)- sediment, 41 
Bag, Hagner, 149 
Balanitis, 64 
Balsamics, action of, 33 
Bandage, Alexander, 171 
Bartholini's glands, infection by 

gonococcus, 276 
Bilateral nephrostom\- in cancer of 
• bladder, 210 

ureterostomy in cancer of blad- 
der, 210 
Bilharziasis, 203 

Bladder, Bilharzia infection of, 203 
cancer of, 204 
bUateral nephrostomy in, 210 

ureterostomy in, 210 
radium in, 212 
diseases of, 188 

291 



292 



INDEX 



Bladder disturbances due to multi- 
ple sclerosis, 200 
to nerve lesions, 200 
to spina bifida, 200, 203 
to syringomyelia, 200 
diverticulum of, 50 

ic-ray of, 52 
encrusted, 195 
examination of, 29 
exstrophy of, 54 
infections of, 189 
lavage of, 19 

in cystitis, 193 
neck, contracture of, 157 
overflow, 126 
paracentesis of, 142, 144 
paralysis due to diphtheria, 200 
to tabes, 198 

to transverse myelitis, 200 
rupture of, 213 
stone in, 212 

after prostatectomy, 156 
syphilis of, 203 
tabetic, 199 
tuberculosis of, 261 
treatment of, 264 
tumor of, 204 
removal of, 207 
thermocoagulation of, 206 
Boric acid in bladder lavage, 19 
Brown-Buerger cystoscope, 28 
Bubo, 61, 62 

Burnam's test for formalin in urine, 
37 

Calculi, oxalate, 253 
phosphatic, 254 
renal and ureteral, 245, 247 
recurrent, 253 
a;-ray of, 247, 254 
vesical, 212 
Cancer of bladder, 204 



Cancer of bladder, bilateral neph- 
rostomy in, 210 
ureterostomy in, 210 
radium in, 212 
of penis, 71 
of prostate, 158, 161 

differential diagnosis of, 130 
radium in, 160 
Caruncle of urethra, 105 
Case reports: 

bladder, encrusted, 195 

tumor removed by fulgura- 
tion, 207 
by operation, 207 
decapsulation for renal hema- 
turia, 227 
diverticulum of bladder, 52 
epididymitis, tuberculous, 265 
hematuria, essential, 218 

of chronic nephritis, 217 
hydronephrosis, 243 
hypernephroma, 221 
impotence due to seminal ve- 
siculitis, 281 
kidney, rupture of, 258 
multiple sclerosis cause of blad- 
der disturbance, 201 
mumps, epididymo-orchitis of, 

179 
nephrectomy for tuberculosis, 

269 
nephropexy, 231 
prostate, cancer of, 161 
prostatectomy, perineal, 154 

suprapubic, 154 
prostatic enlargement, first 

stage, 126 
pyelitis, chronic bilateral, 
241 
of pregnancy, 236 
renal and ureteral stone, re- 
current, 254 



INDEX 



^93 



Case reports: 

renal stone, hematuria the only 

symptom, 247 
seminal vesicle, perineal ab- 
scess from, 110 
vesiculitis, chronic, 117 
non-specific, 118 
syringomyeKa, bladder dis- 
turbance due to, 200 
tabes dorsalis, retention due 

to, 131 
testicle, abscess of, 181 
tumor, abdominal, of splenic 

origin, 223 
ureterolithotomy, 251 
urethritis, acute, and stricture, 
86 
chronic, 92, 93, 94 

in female, 105 
non-specific, 91 
Catheter life for prostatics, 135 
lubricant, 20, 23 
method of fastening in urethra, 

144 
specimen in examination, of urine, 
39 
Catheterization in prostatic ob- 
struction, 142 
of ureters, 31 
retrograde, 100 
Cerv-ix uteri, infection of, by gono- 

coccus, 276 
Chancre, 62 
Chancroid, 61 
Children, cystoscopy in, 31 

pyelitis in, 237 
Chronic cystitis, 196 

urethritis, 87 
Circumcision, indications for, 65 
local anesthesia for, 67 
technic of, 65 
Coccus infection of kidney, 234 



Colic, renal and ureteral, 219 

treatment, 253 
Colon bacillus epididymitis, 185 

infection of kidney, 234 
Complement-fixation test in gon- 
orrhea, 43 
technic of, 43 

value in chrom'c urethritis, 93 
Condylomata, 63 

due to syphilis, 64 
Congenital malformations of genito- 
urinary tract, 49 
Contracture of bladder neck, 157 
Culture of urine, 41 
Cure of gonococcus infections, 120 
Cyst, echinococcus, of kidney, 257 

of urachus, 54 
Cystectomy, 209 
Cystitis, 189 
acute, 191 
alkaline. Bacillus acidophilus in, 

195 
chronic, 196 

causes of, 197 
lavage of bladder in, 193 
Cystoscope, Bro^n-Buerger, 28 

operating, 31 
Cystoscopy, anesthesia in, 28, 262 
spinal, 29 
in children, 31 
indigo-carmine in, 30 
operative, 31 
technic of, 28 
value of, 27 
Cystotomy in two-stage prosta- 
tectomy, 138 
local anesthesia for, 138 
Cysto-urethroscope in posterior 
urethra, 26 

Decapsulation in nephritis, 228 
in renal hematuria, 227 



294 



INDEX 



Diet in lithiasis, 253 

Dietl's crisis, 230 

Dilatation of stricture, 98 

Diphtheria a cause of bladder pa- 
ralysis, 200 

Diverticulum of bladder, 50 
ic-ray in, 52 

Double pelvis, 49 
ureter, 49 

Ducrey's bacillus, 61 

Pystopic kidney, 49, 50 

EcHiNO coccus cyst of kidney, 257 
Edebohl's operation, 228 
Embryoma of kidney, 255 
Encrusted bladder, 195 
Endoscopy in female, 25, 26, 104 

technic of, 25 

value of, 24 
Epididymis, gonococcus infection 
of, 185 

tuberculosis of, 265 
Epididymitis, 183 

acute, treatment of, 186 

due to colon bacillus, 185 
Epididymo-orchitis of mumps, 178, 

179 
Epididymotomy, 186 
Epididymovasectomy, 267 
Epispadias, 55 
Equipment for minor genito-urinary 

surgery, 22 
Essential hematuria, 226 
Exstrophy of bladder, 54 
External urethrotomy, 99 
Extravasation of urine, 101 

Fallopian tubes, infection by gono- 
coccus, 276 
Fehling's test for sugar, 40 
Female, endoscopy in, 25, 104 
gonococcus infection in, 272 



Fever in renal infection, 220 
Fistula of urachus, 54 
Formaldehyd sterihzer, 21 
Formalin in urine, test for, 37 
Fulguration, removal of bladder 

tumor by, 207 
Function, renal, tests of, 44, 45 

Genital tuberculosis, 265 
Genito-urinary surgery, minor, 
equipment for, 22 
technic, 18 
tract, congenital malformations 

of, 49 
tuberculosis, 260 
Gonococci in secretion from pros- 
tate and vesicles, 42 
morphology of, 42 
Gonococcus, arthritis due to. 111 
vaccines in, 112 
cause of sterility, 285 
epididymitis, 185 
infection, cure of, 120 

of Bartholini's glands, 276 
of cervix uteri, 276 
of female, 272 
of prostate, 77, 85 
of Skene's glands, 276 
septicemia. 111 
vulvovaginitis, 272 
Gonorrhea, abortion of, 74 
acute, treatment of, 77 
and marriage, 122 
complement-fixation test in, 43 
cure of, 84 

test for, 121 
in female, 272 
in male, 73 
prevention of, 73 
Gram's stain, 42 

Guinea-pig, inoculation of, detec- 
tion of tubercle bacillus by, 41 



INDEX 



295 



Hagner bag, 149 
Hegonon in urethritis, 79 
Hematocele, 164 

Hematuria associated with ab- 
dominal tumor, 224 

essential, 226 

of chronic nephritis, 217 
Hermaphroditism, 56 
Hexamethylenamin, action of, 34 
Horseshoe kidney, 49 
Hydrocele, 163 

of cord, 174 

radical cure of, 168 

tapping of, 165 
Hydronephrosis, 225, 243 
Hygiene, sex, in impotence, 280 
Hypernephroma, 221, 255 
Hypertrophy of prostate, 124 
Hypospadias, 56 



Impotence, 278 
due to seminal vesiculitis, 281 
role of posterior urethra in, 281 
sex hygiene in, 280 
Incontinence, urinary, in women, 

106 
Indigo-carmine in cystoscopy, 30 
Infection, acute, of prostate, 107 

of seminal vesicles, 107 
Bilharzia, of bladder, 203 
chronic, of prostate, 91 
due to trauma, 19 
gonococcus, cure of, 120 

of female, 272 

of prostate, 77, 85 
of bladder, 189 

of cervix uteri by gonococcus, 276 
of fallopian tubes by gonococcus, 

276 
of kidney, 232, 234 

coccus, 234 



Infection of Skene's glands, 103, 
276 

of vesicles, 77, 85 

renal, fev^er in, 220 
vaccines in, 240 

urinary, salol in, 38 
Inguinal adenitis, 61 
Instruments, sterilization of, 20 
Insufficiency, renal, 225 
Internal urethrotomy, 98 
Irrigator, use in urethritis, 83 

Keyes' instillator, 25, 120 
Kidney, acute hematogenous, 234 

colon bacillus infection of, 234 

cysts of, 257 

diseases of, 216 

dystopic, 49, 50 

embryoma of, 255 

function, tests of, 44 

horseshoe, 49 

infections of, 232, 234 

movable, 228 

polycystic, 225, 257 

rupture of, 257, 258 

single, 49 

stone in, 245 

tuberculosis of, 261 

tumor of, 255 
pyelography in diagnosis of, 
221 

Weigert, 226 

Lactic acid bacilli in alkaline cys- 
titis, 195 

Lavage in pyelitis, 236, 240 
of bladder and urethra, 19 

in cystitis, 193 
of renal pelvis, 236, 240 * 

Lithiasis, diet in, 253 

Lubricant, catheter, 20, 23 



296 



INDEX 



Male, gonorrhea in, 73 

Malformations, congenital, of gen- 
ito-urinary tract, 49 
of penis, 55 

Massage of prostate and vesicles, 
116, 119 

Maydl operation, 55 

Meatotomy, 88 

Morphology of gonococci, 42 

Movable kidney, 228 

Multiple sclerosis cause of bladder 
disturbances, 200, 201 

Mumps, epididymo-orchitis of, 178, 
179 

Myelitis, transverse, cause of blad- 
der paralysis, 200 



Neck of bladder, contracture of, 
157 

Neoplasm of testicle, 183 

Nephrectomy for tuberculosis, 262, 
269 
tuberculin after, 263 

Nephritis, decapsulation in, 228 
hematuria in, 217 

Nephropexy, 230, 231 

Nephroptosis, 228 

Nephrostomy, bilateral, in cancer 
of bladder, 210 

Nerve lesions cause of bladder dis- 
turbances, 200 

Neurasthenia, sexual, 278 



Obstruction, prostatic, 124 
catheterization in, 142 
retention due to, 136 

Oil, sandalwood, action of, S3 
in urethritis, 78 

Otis urethrotome, 98 

Oxalate calculi, 253 



Pain, renal, 219 

Paiacentesis of bladder, 142, 144 
Paral}^sis of bladder due to diph- 
theria, 200 
to tabes, 198 
Paraphimosis, 70 
Pelvis, double, 49 

renal, lavage in, 236, 240 
Penis, cancer of, 71 
diseases of, 61 
malformations of, 55 
Perineal abscess from seminal 
vesicle, 110 
prostatectomy, 154, 161 
prostatotomy, 157 
section for stricture of urethra, 99 
spinal anesthesia in, 102 
Phenolsulphonephthalein test of 

renal function, 45 
Phimosis, 64 
Phosphatic calculi, 254 
Phthalein test, technic of, 45 
Polycystic kidney, 225, 257 
Potassium citrate in urethritis, 78 
permanganate in bladder lavage, 
19 
in urethritis, 78 
tablets of, 23 
Pregnancy, pyelitis of, 235, 236 
Prepuce, tightness of, 64 
Prolapse of urethra, 106 
Prophylaxis, venereal, 73 
Prostate, abscess of, 108 
acute infections of, 107 
adenomatous, 124 
benign enlargement of, 124 
cancer of, 158, 161 
differential diagnosis, 130 
radium in, 160 
chronic infection of, 91 
diseases of, 107 
gonococcus infection of, 77, 85 



INDEX 



297 



Prostate, h\'pertrophy of, 124 

massage of, 116, 119 

secretion from, gonococci in, 42 

small fibrous, 157 

tuberculosis of, 123, 268 
Prostatectomy, 137 

after-treatment of, 156 

anesthesia in, 147 
spinal, 147 

perineal, 153, 154, 161 

postoperative treatment of, 155 

stone in bladder after, 156 

suprapubic, 145, 154 

two-stage, cystotomy in, 138 
Prostatic enlargement, sjTnptoms 
of, 125 

obstruction, 124 

catheterization in, 142 
retention due to, 136 

secretion, stain for, 43 
Prostatics, catheter life for, 135 

management of, 132 
Prostatitis, chronic, 114 

in stricture, 96 

non-specific, 118 
Prostatotom\^ perineal, 157 

lavage in, 236, 240 
Punch, Young's, 157 
Pyelitis, chronic bilateral, 241 

of children, 237 

of pregnancy, 235, 236 

sequelae of, 238 

silver nitrate in, 240 

treatment of, 240 
Pyelography in diagnosis of renal 

tumor, 221 
Pyelonephritis, 234 
Pyuria, sjinptoms of renal disease, 

219 

Radium in cancer of bladder, 212 
of prostate, 160 



Renal colic, 219, 253 

disease, pyuria, symptom of, 219 

urine abnormalities in, 216 
function, tests for, 44, 45 
infections, 232 
fever in, 220 
vaccines in, 240 
insufficiency, 225 
pain, 219 

pel\-is, lavage of, 236, 240 
retention, 243 
stone, 245 
bilateral, 248 

hematuria, only symptom, 247 
recurrent, 254 
rv-ray in, 247 
tumor, 255 
pyelography in diagnosis of, 
221 
Retention due to prostatic obstruc- 
tion, 136 
catheterization in, 142 
to stricture, 97 
to tabes dorsalis, 131 
renal, 243 
Retrograde catheterization, 100 
Rupture of bladder, 213 
of kidney, 257, 258 
of urethra, 95 

Salol in urinary infections, 38 

Salpingitis, treatment of, 276 

Sandalwood oil, action of, 33 
in urethritis, 78 

Sclerosis, multiple, bladder dis- 
turbances due to, 200, 201 

Scrotum, diseases of, 163 
local anesthesia for operations on, 
168 

Sediment, urinary, examination of, 
40 

Semen, examination of, 284 



298 



INDEX 



Seminal vesicles, acute infections 
of, 107 
anatomy of, 109 
diseases of, 107 
massage of, 116, 119 
medication of, 113 
perineal abscess from, 110 
tuberculosis of, 123, 268 
vesiculitis, chronic, 114, 172 
impotence due to, 281 
non-specific, 118 
- vesiculotomy, 113 
Septicemia, gonococcus, 111 
Sex hygiene in impotence, 280 
Sexual neurasthenia, 278 
Silver nitrate in bladder lavage, 19 
in chronic urethritis, 89 
in posterior urethritis, 27, 120 
in pyelitis, 240 
tablets of, 23 
Single kidney, 49 

ureter, 49 
Skene's glands, infection of, 103, 

276 
Sodium acid phosphate a means of 
acidifying urine, 36 
benzoate in urinary infections, 38 
bicarbonate douche in sterility, 
288 
Sounds in chronic urethritis, 88 

in stricture of urethra, 98 
Spermatic cord, diseases of, 174 

hydrocele of, 174 
Spermatocele, 163 
Spermatozoa, abnormalities of, 284 

stained, 43 
Spina bifida cause of bladder dis- 
turbances, 200 
occulta in bladder disturb- 
ances, 203 
Spinal anesthesia in cystoscopy, 29 
in perineal section » 102 



Spinal anesthesia in prostatectomy, 
147 

technic, 148 
Spirochaeta pallidum, 62 
Stain for prostatic secretion, 43 
for tubercle bacillus, 41 
for urethral secretion, 42 
Gram's, for gonococci, 42 
Stained spermatozoa, 43 
Sterility, causes of, 282 
gonococcus, 285 
sodium bicarbonate douche in, 
288 
Sterilization of instruments, 20 
Sterilizer, formaldehyd, 21 
Stone in bladder, 212 

after prostatectomy, 156 
renal and ureteral, 245 

recurrence of, 253, 254 
x-ray of, 247 
Stricture, dilatation of, 98 
in acute urethritis, 86 
in chronic urethritis, 87 
in women, 105 
of urethra, 95 

perineal section for, 99 
sounds in, 98 
prostatitis in, 96 
rules for treatment of, 102 
tuberculous, 96 
urethrotomy for, 98 
Sugar, test for, 40 
Suprapubic prostatectomy, 145, 154 
Syphilis, condylomata due to, 64 
initial lesion of, 62 
of bladder, 203 
of testicle, 182 
Syringomyelia cause of bladder dis- 
turbance, 200 

Tabes dorsalis cause of bladder 
paralysis, 198 



INDEX 



299 



Tabes dorsalis, test for, 131 
Tabetic bladder, management of, 

199 
Tapping of hydrocele, 165 
Technic in genito-urinary surgery, 
18 

of circumcision, 65 

of complement-fixation test, 43 

of cystoscopy, 28 

of endoscopy, 25 
Teratoma of testicle, 183 
Test, Burnam's, for formalin in 
urine, 37 

complement-fixation, 43 

for albumin, 40 

for formalin in urine, 37 

for sugar, 40 

for tabes dorsalis, 131 

of cure of gonorrhea, 121 

of renal function, 44 

phthalein, technic, 45 
Testicle, abscess of, 181 

diseases of, 178 

neoplasm of, 183 

s>T)hilis of, 182 

teratoma of, 183 

torsion of, 176 

trauma of, 178 

tuberculosis of, 182 

undescended, 57 
Thermocoagulation of bladder tu- 
mors, 206 
Torsion of spermatic cord, 176 

of testicle, 176 
Transverse myelitis cause of blad- 
der paralysis, 200 
Tubercle bacilli in urine, detection 
of, 41 
stain for, 41 
Tuberculin after nephrectomy, 263 
Tuberculosis, genital, 265 

genito-urinary, 260 



Tuberculosis, nephrectomy for, 262, 
269 
of bladder, 261 

treatment, 264 
of epidid>Tnis, 265 
of kidney, 261 
of prostate, 123, 268 
of testicle, 182 
of vesicles, 123, 268 
Tuberculous stricture, 96 
Tumor, abdominal, of renal origin, 
220 
of bladder, 204 

thermocoagulation of, 206 
of kidney, 255 
renal, 255 
pyelography in diagnosis of, 
221 

Undescended testicle, 57 
Urachus, cyst of, 54 

fistula of, 54 
Ureter, diseases of, 216 

double, 49 

single, 49 
Ureteral colic, 219, 253 
recurrent, 254 

stone, 245 
Ureterolithotomy, 251 
Ureterosigmoidostomy, 55 
Ureterostomy, bilateral, in cancer 

of bladder, 210 
Ureters, catheterization of, 31 
Urethra, anterior, examination of, 
26 

caruncle of, 105 

diseases of, 73 
in women, 103 

female, endoscopy of, 25, 26, 104 

lavage of, 19 

method of fastening catheter in, 
144 



300 



INDEX 



Urethra, posterior, appearance of, 
27 
cysto-urethroscope in, 26 
role in impotence, 281 
urethritis involving, 81 
prolapse of, 106 
rupture of, 95 
stricture of, 95 
in women, 105 
perineal section for, 99 
sounds in, 98 
Urethral instrumentation, asepsis 
in, 20 
secretion, stain for, 42 
Urethritis, acute, and strictur , 86 
in women, 103 
treatment of, 77 
argyrol in, 79, 276 
chronic, 87 

in women, 103, 105 
silver nitrate in, 89 
sounds in, 88 
stricture in, 87 

value of complement-jBxation 
test in, 93 
cure of, 89 
hegonon in, 79 

involving posterior urethra, 81 
non-specific, 90, 91 
posterior, silver nitrate in, 27, 

120 
potassium citrate in, 78 
permanganate in, 78 
use of irrigator in, 83 
Urethrotome, Otis, 98 
Urethrotomy, external, 99 
for stricture, 98 
internal, 98 
Urinalysis, 39 

Urinary antiseptics, action of, 33 
administration before instru- 
mentation, 20 



Urinary incontinence in women, 
106 

infections, salol in, 38 

sodium benzoate in, 38 
sediment, bacteria in, 41 
examination of, 40 
Urination, disturbances of, 188, 220 
Urine abnormalities in renal dis- 
ease, 216 
acidity increased by sodium acid 

phosphate, 36 
culture of, 41 
examination of, 39 
extravasation of, 101 
test for formalin in, 37 
tubercle bacillus in, 41 
Urotropin. See Hexamethylena- 
min, 35 

Vaccines in gonococcus arthritis, 
112 
in renal infections, 240 
Varicocele, 175 
Vaso-epididymostomy, 287 
Venereal prophylaxis, 73 

warts, 63 
Vesical calculus, 212 
Vesicles, infection of, 77, 85 
massage of, 116, 119 
seminal, acute infections of, 107 
massage of, 116, 119 
perineal abscess from, 110 
tuberculosis of, 123, 268 
Vesicular secretion, gonococci in, 42 

stain for, 43 
Vesiculitis, seminal, chronic, 117 
due to impotence, 281 
non-specific, 118 
Vesiculotomy, seminal, 113 
Vulvovaginitis, 272 
argyrol in, 274 
gonococcus, 272 



INDEX 



301 



Warts, venereal, 63 
Weigert kidney, 226 
Women, diseases of urethra in, 103 
urinary incontinence in, 106 



X-ray of bladder diverticulum, 52 
of renal stone, 247 

Yoitng's punch, 157 



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Musser and Kelly*s Treatment 



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Clinical Medicine. By William Hanna Thomson, M.D., 
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Tousey's Medical Electricity, 
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Medical Electricity, Rontgen Rays, and Radium. By 

Sinclair Tousey, M. D., Consulting Surgeon to St. Bar- 
tholomew's Hospital, New York. Octavo of 1219 pages, with 
80 T illustrations, 19 in colors. Cloth, t'l-^o net. 

Published February, 1915 
SECOND EDITION. RESET 

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The book has been enriched by including several of Machado's tabular 
classifications of electric methods, effects, and uses. 

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is omitted. It tells you how to equip your office, and, more than that, how to 
use your apparatus, explaining away all difficulties. It tells you just how to 
apply these measures in the treatment of disease. The chapters on dental 
radiography are particularly valuable to those interested in dental work. 



Abbott's Medical Electricity 

Medical Electricity. By George Knapp Abbott, 
M. D., Dean and Professor of Physiologic Therapy and 
Practice, College of Medical Evangelists, Loma Linda, Cali- 
fornia. i2mo of 132 pages, illustrated. Cloth, ^1.25 net. 

This new work gives the nurse the essentials of this subject. Dr. 
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Published April, 1915 



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Gant's Work on Diarrhea 

Diarrhea, Inflammatory and Parasitic Diseases of the 
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and Anus, New York Post-Graduate Medical School and Hospital. 
Octavo of 604 pages, with 181 illustrations. Cloth, ^6.00 net. 

Published June, 1915 

ILLUSTRATED 

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Octavo of S7S pages, with 250 illustrations. By Samuel G. Gant, M. D., LL. D., 
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DIAGNOSIS AND TREATMENT 



Cabot's Differential Diagnosis 

Differential Diagnosis. Presented througn an analysis of 
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VOLUME I [Third Edition— January, 1915]: Headache, pain in various 
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VOLUME 2 : Treats of abdominal and other tumors, vertigo, diarrhea, 
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hemoptysis, edema of legs, frequent micturition and polyuria, fainting, hoarse- 
ness, pallor, swelling of arm, delirium, palpitation and arhythmia, tremor, 
ascites and abdominal enlargement — 19 symptoms and 317 cases. Dec, 1914 



Morrow's Diag'nostic and 
Therapeutic Technic 



Diagnostic and Tlierapeutic Technic. By Albert S. 
Morrow, M.D., Adjunct Professor of Surgery, New York Poly- 
clinic. Octavo of 830 pages, with 860 original line drawings. 

Cloth, $6.00 net. Published January, 1915 

SECOND EDITION 

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Garrison's History of Medicine 

History of Medicine. With Medical Chronology, Biblio- 
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Washington, D. C. Octavo of 905 pages, illustrated. Cloth, 

^7.00 net. Second Edition published September, 1917 

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Exercise in Education and Medicine. By R. Tait 
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Bonney's Tuberculosis Second Edition-May. 1910 

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Anders* 
Practice of Medicine 

A Text=Book of the Practice of Medicine. By James 
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Physical Diagnosis. By John C. DaCosta, Jr., Asso- 
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Strouse and Perry's Food 
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Food for the Sick. By Solomon Strouse, M. D., Pro- 
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i2mo of 270 pages. Cloth, $1.50 net. PubUshed August, 1917 

FOR PHYSICIAN. NURS£» AND PATIENT 

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Friedenwald Cf Ruhrah on Diet 

Diet in Health and Disease. By Julius Friedenwald, 
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i6mo of 134 pages. By Gary Eggleston, M. D., Instructor in Pharmacology at 
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Kemp on Stomach, 
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Diseases of the Stomach, Intestines, and Pancreas, 

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THIRD EDITION-published April, 1917 

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Dastedo's Materia IVledica, Pharmacology, 
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Faught's Blood-Pressure 

Blood=Pressure from the Clinical Standpoint. By 

Francis A. Faught, M. D., formerly Director of the Laboratory 
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Anders and Boston's Medical 
Dia£(nosis 

A Text-Book of Medical Diagnosis. By James M. An- 
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Napoleon Boston, M. D., Professor of Physical Diagnosis, 
University of Pennsylvania. Octavo of 1248 pages, with 466 
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SECOND EDITION 

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De&derick ^ Thompson's Endemic Diseases of South 

Endemic Diseases of the Southern States. By William 
H. Deaderick, M. D., Member American Society of Tropical Medicine; 
and LOYD Thompson, M. D., Charter Member American Association of 
Immunologists. Octavo of 546 pages, illustrated. Cloth, ;^5.oo neL 

PubUshed March, 1916 

This new work is really a collection of monographs on malaria, blackwater fever, 
pellagra, amebic dysentery, hookworm disease, and other intestinal parasites 
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the correct interpretation of the symptoms presented, and every modern means of 
value in the prevention and treatment of the diseases discussed. 



Smith's What to Eat and Why Second Edition 

What to Eat and Why. By G. Carroll Smith, M. D., Boston. 
l2mo of 377 pages. Cloth, j^2.75 net. Published September, 1915 

With this book you no longer need send your patients to a specialist to be dieted— 
you will be able to prescribe the suitable diet yourself, just as you do other forms ol 
therapy. Dr. Smith gives 'the why" of each statement he makes. It is this knowing 
why which gives you confidence in the book, which makes you feel that Dr Smith 
knows. 



Ward's Bedside Hematology 

Bedside Hematology. By Gordon R. Ward, M. D., Fellow of 
the Royal Society of Medicine, London. England. Octavo of 394 
pages, illustrated. Cloth, $3.50 net. ' PubUshed AprU, 1914 



Slade's Physical Examination ^ Diagnostic Anatomy 

Physical Examination and Diagnostic Anatomy. By Charles 
B. Slade, M. D., Chief of Clinic in General Medicine, University and 
Bellevue Hospital Medical College. i2mo of 150 pages, illustrated. 
Cloth, $1.25 net. Second Edition— published September, 1916 



Todd's Clinical Diagnosis New (4th) Edition 

Clinical Dl\gnosis. By James Caaipbell Todd, M. D., Professor 
of Clinical Pathology, University of Colorado, Denver. i2mo of 625 
pages, illustrated. Cloth, ^3.00 net. Published June, 1918 



Lusk's Food in War Time 

Food in War Time. By Graham Lusk, Ph.D., Sc.D. 50 pages. 
Cloth, 50 cents net. Published February, 1918 

Here you have a practical exposition of the science of nutrition as applied to the daily 
menu. You are shown how to conserve the food supply, and at the same time preserve 
efficiency and health. Nutritive values of every-day articles of food are given. 



12 SAUNDERS' BOOKS ON 

Norris 6? Landis' 
Physical Diag'nosis 

Physical Diagnosis. Part I: By George William 
NoKRis, A. B., M. D., Associate in Medicine at the University 
of Pennsylvania. Part II: By H. R. M. Landis, A. B., M. D., 
Director of Clinical and Sociological Department of the Phipps 
Institute, Philadelphia. Octavo of 782 pages, with 413 illus- 
trations, mostly original. Cloth, $7.00 net. Published August, 1917 

This work presents an admirable combination of the theory and appli- 
cations of physical diagnosis. It is complete down to the last detail. The 
first part takes up the methods in themselves. Inspection, palpation, per- 
cussion, and auscultation are completely covered in the examination both 
of the lungs and of the heart. The second part takes up the particular 
diseases of the bronchi, of the lungs, of the pleura, diaphragm, pericardium, 
heart and aorta, and shows you exactly how to determine the diagnosis 
by the symptoms and findings. You get here the application of the four 
methods to your daily clinical work. 



Carman Cf Miller's 
X-ray Diagnosis 

Rontgen Diagnosis of Disease of the Alimentary 
Canal. By Russell D. Carman, M. D., Head of Section on 
Rontgenology, and Albert Miller, M. D., Second Assistant 
in Section on Rontgenology, Division of Medicine in The Mayo 
Clinic, Rochester, Minn. Octavo of 558 pages, with 504 illus- 
trations. Cloth, ^6.00 net. Published May, 1917 

This work takes up the diagnosis of disease of the alimentary tract, 
following its course from the esophagus to the rectum. You are told what 
apparatus is needed, and exactly how to use it, with formulas for the barium 
meal and enema. You are given the Rontgen appearance of the normal 
organ under discussion, what appearances signify abnormality, and exactly 
how to detect abnormality. Then you get the rontgenologic symptoms of 
every disease of the organ, followed by several actual examples of each to 
show individual variations, and an extensive bibliography on every topic. 
A few of the important topics treated are early cancer, diverticula, gastrop- 
tosis, "hunger-pain" in duodenal ulcer, Lane's kinks, auto-intoxication, 
and intestinal stasis. 



THERAPEUTICS AND MATERIA MEDICA 13 



Hinsdale's Hydrotherapy 

Hydrotherapy : A Treatise on Hydrotherapy in General ; 
Its Application to Special Affections; the Technic or Processes 
Employed, and the Use of Waters Internally. By Guy Hinsdale, 
M. D., Fellow of the Royal Society of Medicine of Great Britain. 
Octavo of 466 pages, illustrated. Cloth,^3.5o net. 

Published August, 1910 
The'^Medical Record 

" We cannot conceive of a work more useful to the general practitioner than this, nca* 
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work." 



Kelly*s Cyclopedia of American 
Medical Biog(raphy 

Cyclopedia of American Medical Biography. By How- 
ard A. Kelly, M. D., Johns Hopkins University. Two octavos 
of 525 pages each, with portraits. Per set: Cloth, Si 0.00 net. 

PubUshed April, 1912 

Dr. Kelly, in these two handsome volumes, presents concise, yet com- 
plete biographies of those men and women who have contributed notewor- 
thily to the advancement of medicine in America. Dr. Kelly's reputation for 
painstaking care assures accuracy of statement. There are about one thousand 
biographies included. 



Arny*s Pharmacy 



New (2d) Edition 



Principles of Pharmacy. By Henry V. Arny, Ph. G., 
Ph. D., Professor of Chemistry, New York College of Phar- 
macy. Thoroughly revised and reset throughout. Based on 
the ninth edition of the United States Pharmacopoeia and the 
fourth revision of the National Formulary. Octavo of 1056 
pages, with 246 illustrations. Cloth, $5.50 net. 

PubUshed March, 1917 

Bohm and Painter's Massage 

Massage. By Max Bohm, M. D., of Berlin, Germany. Edited? 
with an Introduction, by CHARLES F. Painter, M. D., Professor of 
Orthopedic Surgery at Tufts College Medical School, Boston. Octaro 
of 91 pages, with (^l practical illustrations. Cloth, I1.75 net. June, 1913 



f4 SAUNDERS' BOOKS ON 

THE BEST /inierican standard 

Illustrated Dictionary 

The New (9th) Edition, Reset 

The American Illustrated Medical Dictionary. By W. A. 

Newman Borland, M. D., Editor of "The American Pocket 
Medical Dictionary." Octavo of 1 179 pages. Flexible leather, 

^5.00 net j with thumb index, ^5.50 net. Published September, 1917 
OVER 2000 NEW WORDS 

Howard A. Kelly, M. D., Johns Hopkins University, Baltimore. 

" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such conve- 
nient size. No errors have been found in my use of it." 



Sollmann*s Pharmacolo£(y 

A Manual of Pharmacology: Its Applications to Therapeutics 
AND Toxicology. By Torald Sollmann, M. D., Professor of Pharma- 
cology and Materia Medica in the School of Medicine of Western Reserve 
University, Cleveland.- Octavo of 901 pages, illustrated. Cloth, $4.50 net. 

w A ^|T A I This is the text or reference volume. Throughout the 

work the relation of pharmacology to the practice of 
medicine is forcibly emphasized. Those drugs that you actually use in 
your practice are discussed extensively, while those used less frequently are 
dismissed with less consideration. All the new remedies are included, with 
detailed instructions for their use: Vaccines, serums, salvarsan, neosalvar- 
san, pituitary extract, emetin — all those new remedies of the Pharmacopoeia 
being so extensively discussed and employed. Every worthwhile develop- 
ment in the field of pharmacology is included. Published February, 1917 

LABORATORY GUIDE. ^^^ '^''"''' ''' ^^^' ^^^^'^^'^y 

Guide present no difl&culty in 
technic, and require little help from the instructor. They teach you how 
to teach yourself. Special stress is laid on facts with direct practical bear- 
ing. " Technical Notes" are introduced for more detailed information for 
the instructor and investigator. 

A Laboratory Guide in Pharmacology. By Torald Sollmann, M. D. 
Octavo of 355 pages, illustrated. Pubhshed February, 1917 Cloth, $2.50 net. 



MATERIA MEDIC A AND THERAPEUTICS. I J 

American Pocket Dictionary „^^ (,„^) ^^^^^ 

The American Pocket Medical Dictionary. Edited' by W. 
A. Newman Borland, M.D. Flexible leather, with gold edges, $1.25 
net ; with thumb index, $1.50 net. PubUshed September 1917 

Cohen and Eshner's Diagnosis. Second Edition, 1900 

Essentials of Diagnosis. By S. Solis-Cohen, M. D., and A. A. 
Eshner, M. D. Post-octavo, 382 pages ; 55 illustrations. Cloth, $\.2<, 
net. In Saunders' Question- Co7npend Series. 

Sollmann's Actions of Drugs J«st out 

The Actions of Drugs. By Torald Sollm-ANN, M. D., Professor 
of Pharmacology and :SIateria :Medica, Western Reserve University. 
i2mo of 213 pages. Cloth, Si. 50 net. Published October, 1917 

Deaderick on Malaria 

Practical Study of Malaria. By William H. Deaderick, 
M. D., Member American Society of Tropical Medicine. Octavo of 
402 pages, illustrated. Cloth, $4.50 net. Published November, 1909 

Goepp's State Board Questions New (4th) Edition 

State Board Questions and Answers. By R. Max Goepp, 
M. D-, Professor of Clinical Medicine, Philadelphia Polyclinic. Octavo 
of 715 pages. Published March, 1917. Cloth, $4.25 net. 

Niles on Pellagra Second Edition-January, 1916 

Pellagra, By George M. Niles, M. D.,. Gastro-enterologist to 
the Georgia Baptist Hospital, Atlanta. Octavo of 253 pages, illustrated. 
Cloth, $3.00 net. 

Arnold's Medical Diet Charts 

Medical Diet Charts. Prepared by H. D. Arnold, M. D,, 
Professor of Clinical Medicine, Tufts Medical College, Boston. Single 
charts, 5 cents; 50 charts, $2.00 net; 500 charts, ^iS.oo net; looo 
charts, ^30.00 net. 

Thornton's Dose-Book Fourth Edition 

DosE-BooK and Mantjal of Prescription Writing. By E. Q. 
Thornton, M. D., Assistant Professor of Materia Medica, Jefferson 
Medical College, Philadelphia. Post-octavo, 410 pages, illustrated. 
Flexible leather, S2.00 net. Published September, 1909 

Lusk on Nutrition New (3d) Edition, 

ELEilENTS OF THE SCIENCE OF NUTRITION. By Gr.AH.\M LuSK, 

Ph. D., Professor of Physiology in Cornell University ]\Iedical School. 
Octavo of 641 pages. Cloth, $4.50 net. Published July, 1917 

"I shall recommend it highly. It is a comfort to have- such a discussion of the 
subject."— Lewellys F. Barker, M. D., Professor oJ the Principles and Practice of 
Medicine, Johns Hopkins University. 



1 6 SA UNDEkS' B O OKS ON 

Stevens* Therapeutics ^>ft^ Edition 

A Text-Book of Modern Materia Medica and Therapeutics. 
By A. A. Stevens, A.M., M.D., Lecturer on Physical Diagnosis in the 
University of Pennsylvania. Octavo of 675 pages. Cloth, I3.S0 net. 

Dr, Stevens' Therapeutics is one of the most successful works on the subject ever 
published. In this new edition the work has undergone a very thorough revision, 
and now represents the very latest advances. Published September, 1909 

The Medical Record, New York 

" Among the numerous treatises on this most important branch of medical practice, 
this by Dr. Stevens has ranked with the best." 

Butler's Materia Medica ««*** Edition 

A Text-Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph.G., M.D., Professor and Head 
of the Department of Therapeutics and Professor of Preventive and 
Clinical Medicine, Chicago College of Medicine and Surgery, Medical 
Department Valpariso University. Octavo of 702 pages, illustrated. 
Cloth, ^4.00 net. Published June, 1908 

For this sixth edition Dr. Butler has entirely remodeled his work, a great part hav- 
ing been rewritten. All obsolete matter has been eliminated, and special attention 
has been given to the toxicologic and therapeutic effects of the newer compounds. 

Sahli's Dia£(nostic Methods Second Edition, Reset 

A Treatise on Diagnostic Methods of Examination. By Prof. 
Dr. H. Sahli, of Bern. Edited by Nath'l Bowditch Potter, M. D., 
Columbia University, Octavo of 1225 pages, profusely illustrated. 
Cloth, $6.50 net. PubUshed January, 1911 

Saunders' Pocket Formulary Ninth Edition— January, 1909 

Saunders' Pocket Medical Formulary. By William M. Powell, 
M. D. Containing 1900 formulas from the best-known authorities. 
In flexible leather, with side index, wallet, and flap. $1.75 net. 

Camac's Epoch -Making Contributions 

Epoch-making Contributions to Medicine and Surgery. By 
C. N. B. Camac, M. D. of New York City. Octavo of 450 pages, 
with portraits. Artistically bound, $4.00 net. January, 1909 

Stevens* Practice of Medicine New (loth) Edition 

A Manual of the Practice of Medicine. By A. A. Stevens, 
A. M., M. D., Professor of Therapeutics and Clinical Medicine, 
Woman's Medical College, Philadelphia. Post-octavo, 629 pages, 

illustrated. Cloth, $2.75 net. Published July, 1915 



